1 STATE OF MICHIGAN IN THE CIRCUIT COURT FOR COUNTY OF GRAND TRAVERSE 2 13TH MICHIGAN JUDICIAL CIRCUIT 3 ELIZABETH MORDEN, as PERSONAL Case No.: 04-25311-NM 4 REPRESENTATIVE OF THE ESTATE Hon. Philip E. Rodgers, Jr. CHRISTOPHER ROBIN MORDEN, 5 Plaintiff, 6 v 7 GRAND TRAVERSE COUNTY; GRAND TRAVERSE COUNTY JAIL; MARILYN CONLON, M.D., in 8 her individual capacity; WELL-SPRING PSYCHIATRY, P.C.; MARGARET SCHOFIELD, R.N., 9 in her individual capacity; ELAINE LOZEN, R.N. (FORMERLY SN), in her individual capacity; 10 SANDI MINOR, R.N., in her individual capacity; DAVID WILCOX, D.O., in his individual capacity; 11 NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY, f/k/a GREAT LAKES COMMUNITY MENTAL HEALTH; 12 ANNE MARIE BAASE, in her individual capacity; JIM TALBOTT, in his individual capacity; 13 TONY KARLIN, in his individual capacity; and SHERIFF SCOTT FEWINS, in his individual 14 capacity; Individually and Jointly and Severally, 15 Defendants. ______________________________________________/ 16 The deposition of MARILYN E. CONLON, M.D., taken before 17 Me, Reatha M. Cochran, CSR-2427, Certified Shorthand Reporter 18 and Registered Professional Reporter and Notary Public, at the 19 Governmental Center, 440 Boardman, Traverse City, Michigan, on 20 Tuesday, June 7, 2005, commencing at about 12:19 p.m. 21 APPEARANCES: 22 SACHS, WALDMAN 23 BY: LINDA TUREK, ESQ. (P53564) 1000 Farmer Street 24 Detroit, MI 48226 25 On behalf of Plaintiff. 2 1 APPEARANCES CONTINUED: 2 BURNHEIMER + COMPANY, P.C. BY: ELEANOR E. LYNN, ESQ. (P44294) 3 440 West Front at Oak Street Traverse City, MI 49684 4 On behalf of Defendant Dr. Wilcox. 5 PLUNKETT & COONEY, P.C. 6 BY: CHARLES H. GANO, ESQ. (P26998) 303 Howard Street 7 Petoskey, MI 49770 8 On behalf of Defendant Dr. Conlon. 9 CUMMINGS, McCLOREY, DAVIS & ACHO BY: BRADLEY DEAN WIERDA, ESQ. (P63811) 10 3939 M-72 E Williamsburg, MI 49690 11 On behalf of Defendant Nurses and Sheriff 12 Fewins. 13 JOHNSON, ROSATI, LaBARGE, ASELTYNE & FIELD, P.C. BY: MARGARET T. DEBLER, ESQ. (P43905) 14 34405 West Twelve Mile Road, Suite 200 Farmington Hills, MI 48331-5627 15 16 On behalf of Defendant Northern Lakes CMH Authority and Great Lakes CMH. 17 ALSO PRESENT: Elizabeth Morden 18 Leslie Morden David Wilcox, D.O. 19 20 21 22 23 24 25 3 1 EXAMINATION_INDEX ___________ _____ 2 WITNESS: MARILYN E. CONLON, M.D. PAGE 3 Examination by Ms. Turek 4 4 Examination by Ms. Lynn 146 5 Re-Examination by Ms. Turek 152 6 Examination by Ms. Debler 154 7 Re-Examination by Ms. Turek 155 8 Re-Examination by Ms. Lynn 155 9 Re-Examination by Ms. Turek 156 10 Re-Examination by Ms. Lynn 159 11 * * * * * 12 13 EXHIBIT_INDEX _______ _____ 14 EXHIBIT PAGE 15 No exhibits were marked. 16 * * * * * 17 18 19 20 21 22 23 24 25 4 1 Tuesday, June 7, 2005 2 Traverse City, Michigan 3 12:19 p.m. 4 MARILYN E. CONLON, M.D., 5 a witness herein, was called for examination, and after 6 having been first duly sworn was examined and testified as 7 follows: 12:19P 8 MS. TUREK: This is a deposition pursuant to 9 notice and agreement among counsel and in accordance with 10 the Michigan Rules of Evidence and the Michigan Court 11 Rules. 12 EXAMINATION 13 BY MS. TUREK: 14 Q. Please state your full name. 15 A. Marilyn Eileen Conlon, M.D., Ph.D. 16 Q. Have you ever been known by any other name? 17 A. No. 18 Q. You provided your attorney with a curriculum vitae. Do 19 you recall that? 20 A. Yes. 21 Q. Is that curriculum vitae that you provided to your 22 attorney up-to-date and current? 23 A. No. 24 Q. What changes would you make to that C.V.? 25 A. I have additional presentations, a year's worth, that are 5 1 very typical to the ones that are several pages long. No 2 changes there except for additional dates of speaking 3 engagements. 4 Q. How many additional dates? 12:20P 5 A. Approximately twelve. 6 Q. Do you have a listing of those? 7 A. Not available at the present time. 8 Q. Can you summarize those twelve speaking engagements? 9 A. There are approximately four additional speaking 10 engagements for Janssen Pharmaceutical Companies. There 11 are approximately six additional speaking engagements for 12 Bristol-Myers Squibb and Otsuka Pharmaceutical Companies 13 and two unsponsored speaking engagements in the community. 14 Q. The two unsponsored in the community, what did those 15 involve? 16 A. Presentations to the community on various subjects such as 17 metabolic abnormalities with the use of antipsychotic 18 medication. 12:21P 19 Q. And that was both of the community speeches? 20 A. I also believe I may have spoken on either depression or 21 anxiety one time last year. 22 Q. Did you have any handouts for any one of the twelve 23 speaking engagements? 24 A. No, ma'am. 25 Q. The community speech that you gave with regard to the 6 1 metabolic abnormalities with the use of antipsychotics, 2 can you summarize that speech? 3 A. No, ma'am, I cannot. 4 Q. What type of metabolic abnormalities can occur with the 5 use of antipsychotic medications? 6 A. They are numerous. Usually the ones we focus on are 7 glucose intolerance, hypolipidemia, hypocholesterolemia, 8 hypoprolactemia, occasionally QTC elongation which is not 9 necessarily a metabolic abnormality but is a side effect 10 of some medications. 12:22P 11 Q. Is a metabolic abnormality fever? 12 A. Not that we typically discuss. 13 Q. Is it something that you discussed at the community 14 presentation? 15 A. No, ma'am. 16 Q. Did you discuss muscle rigidity in association with 17 antipsychotic medications at the community presentation? 18 A. No, ma'am. 19 Q. Was the community presentation taped? 20 A. Not to my knowledge. 21 Q. Who was in the audience for the community presentation? 22 A. Community members. 23 Q. Who set this speaking engagement up for you? 24 A. At the present time, I can't recall. I'm not prepared to 25 answer that question. Sorry. 7 12:23P 1 Q. That's okay. You would agree that an irregular pulse is a 2 metabolic abnormality that's associated with antipsychotic 3 medication administration? 4 A. Could you please clarify your question? 5 Q. Sure. You would agree that an irregular pulse is a 6 metabolic abnormality? 7 A. You repeated exactly the same words. Could you clarify 8 your question? 9 Q. Sure. What part don't you understand? 10 A. Abnormal pulse or irregular pulse. That can mean multiple 11 things. 12 Q. An irregular pulse can mean multiple things to you? 13 A. Sure. 14 Q. What does an irregular pulse mean to you? 15 A. It could be irregularly irregular. It could be regularly 16 irregular. It could number of different abnormalities. 17 Q. In association with antipsychotic medication, you're aware 18 that a side effect of administration of the same is 19 irregular pulse, right? 20 A. Not necessarily a side effect of antipsychotic medication 21 is an irregular pulse. 22 Q. We're going to be here all day, but that's okay with me. 12:24P 23 A. I'm just trying to answer your questions as you've asked 24 me. 25 MR. GANO: You could be a little more precise, I 8 1 think, than an irregular pulse. 2 MS. TUREK: Sure. 3 MR. GANO: I don't think that's the terms in 4 which physicians speak. 5 Q. (MS. TUREK) An irregular pulse is not? What term, 6 medical term would you use to describe an irregular pulse? 7 A. I would use -- I would be more specific what the irregular 8 pulse meant. 9 Q. Just like in your documentation on Christopher Morden, 10 more specific like that, you mean? 11 MR. GANO: I'll object to the form of the 12 question. What documentation as to Christopher Morden? 13 MS. TUREK: Okay. 14 MR. GANO: If you want to ask her questions 15 about documentation, then you need to identify what 16 documentation; otherwise, she will not answer the 17 question. 18 MS. TUREK: Okay. I gotcha. 19 Q. (MS. TUREK) You went to medical school, right? 20 A. Yes, ma'am. 21 Q. You were told how assess for a pulse, right? 22 A. Yes, ma'am. 23 Q. And how do you assess for a pulse? 24 A. There are multiple ways to do that. 25 Q. Sure. What are those multiple ways? 9 1 A. You can use a stethoscope or you can palpate a pulse at 2 the radial pulse. 3 Q. You had testified earlier that there's irregular pulse and 4 then there's an irregularly irregular pulse, right? With 5 antipsychotic medications, are there any effects on the 6 pulse and/or heart rate? 12:25P 7 A. Yes. 8 Q. What effects are those? 9 A. If there's an elongation of the QTC as occurs with our 10 newer antipsychotic medications and there's a black box 11 warning according to that. A patient could potentially be 12 at risk for cardiac arrest. 13 Q. So this QTC, what is that? 14 A. QTC is a part of an EKG. It's a P, an R, and a QTC and a 15 recovery, sometimes referred to as a U wave. 16 Q. And QTC stands for what? 17 A. I don't think it has a specific -- a Q-T-C don't mean 18 anything specific. A C means corrected, a QT interval 19 that's corrected. It is a part of a leaving of the 20 baseline of the heart that corresponds to electrical 21 depolarization of a heartbeat which causes blood to be 22 pushed through your system. 12:26P 23 Q. And you're suggesting that if there's a QTC elongation, 24 there may be an irregular pulse? 25 A. No. I'm not suggesting that. 10 1 Q. I'm sorry. I misunderstood your testimony then. 2 A. You asked me are there cardiac changes with antipsychotic 3 medications and I said, yes, there can be. 4 Q. Are there pulse changes with the administration of 5 antipsychotic medications, pulse rate and rhythm? 6 A. There are rate and rhythm changes with antipsychotic 7 medications. Some, yes. 8 Q. And those rate and rhythm changes would evidence 9 themselves as an irregular pulse, correct? 10 A. Not necessarily. 11 Q. What do you mean by that? 12:27P 12 A. Well, what you would pick up with an elongated QTC is 13 bradycardia which is that the heart rate is continuing to 14 slow down and eventually it stops. 15 Q. And the heart rate continuing to slow down, you're saying 16 that would be a progressive continuation, decrease in 17 rate, progressively decreasing rate? 18 A. I don't know the answer to that question because I don't 19 think I understand that question. 20 Q. Sure. You just testified that the heart rate would 21 continue to slow down -- 22 A. Right. 23 Q. -- and then ultimately might stop, right? 24 A. Right. 25 Q. Are you saying that if antipsychotic medications are 11 1 provided to a patient, one of the side effects that might 2 occur is this QTC prolongation or elongation -- 3 A. Right. 4 Q. -- that the heart rate would decrease progressively? 12:28P 5 A. Putting the patient at risk to go into ventricular 6 failure. I'm not familiar with the literature supporting 7 that progression so I'm having a difficult time answering 8 your question. But when one takes an EKG as a baseline 9 and takes an EKG after one is on these antipsychotic 10 medications, if there is an elongation of the QTC past 500 11 milliseconds, then one is at risk for something called 12 Torsades de Pointes which is in essence a stopping of the 13 heart. 14 Q. When you provided the community in-service, did you give 15 information with regard to QTC elongation? 16 A. No, ma'am. 17 Q. Did you say that -- did you tell the community that 18 there's a possibility the heart rate might slow down and 19 ultimately kill the patient? 20 A. No, ma'am. 21 Q. Do you believe an EKG should be done as a baseline study 22 prior to administering any antipsychotic medications? 23 MR. GANO: Let me object to the form of the 24 question. Are you asking if -- when you say should be 25 done, are you asking is it the standard of care -- 12 1 MS. TUREK: Sure. 2 MR. GANO: -- for a board certified 3 psychiatrist? 12:30P 4 MS. TUREK: Sure. 5 MR. GANO: I think you need to be more specific 6 with the form of the question. 7 MS. TUREK: I gotcha. 8 Q. (MS. TUREK) Your attorney brings up a good point here. 9 Are you familiar with the phrase, standard of care? 10 A. Yes, I am. 11 Q. All right. For the purposes of this deposition, can we 12 agree that the standard of care is something which a board 13 certified psychiatrist of ordinary learning, judgment, or 14 skill in psychiatry would do under the same or similar 15 circumstances? 16 A. That's my belief of standard of care. 17 Q. All right. Do you believe that it's the standard of care 18 for a psychiatrist to order a baseline EKG prior to 19 prescribing any antipsychotic medications? 20 A. Currently, that is not the standard of care. It is 21 evolving to be the standard of care but currently is not 22 the standard of care. 12:31P 23 Q. What do you base that answer on? 24 A. Evolving literature. 25 Q. Which literature is that? 13 1 A. Risk factors that are documented in the literature such as 2 the Green Journal, the New England Journal of Medicine, 3 and JAMA, as well as Clinical Psychopharmacology. There 4 is one more. Practicing Psychiatry. 12:32P 5 Q. Those are all journal names that you just listed out? 6 A. Those are ones that come to my office that I periodically 7 review the table of contents and make a decision about 8 whether to pursue reading them or to be given to the unit 9 file. 10 Q. What is the unit file? 11 A. The unit file is in the hospital. I'm the medical 12 director of the psychiatric mental health unit and make 13 all these journals available to the nursing staff there so 14 they can stay up on their education. 15 Q. Do you believe any of those articles that you've read with 16 regard to the standard of care and/or a baseline EKG are 17 authoritative? 18 A. Could you ask that question in a different manner, please? 19 Q. Sure. Do you rely on those journals to deliver care and 20 treatment to your patients? 21 A. I rely on those journals to inform me with regard to what 22 the current standard of care is, but I rely on my 23 schooling and years of experience in toto to treat a 24 patient. 12:33P 25 Q. Do you believe that those journals are authoritative? 14 1 A. They are peer reviewed which, therefore, makes them 2 authoritative. 3 Q. Does that mean you believe they are authoritative? 4 A. Yes, ma'am. 5 Q. The four -- I beg your pardon -- the ten presentations you 6 provided for drug companies, what did those ten 7 presentations involve? 8 A. With the changes in the pharmaceutical presentations, they 9 now consist of lunches and dinners where one sits down 10 with the faculty and/or staff invited to that event and a 11 conversation is had with the members at the table without 12 usually benefit of any additional materials about 13 potential side effects, about my personal experience, even 14 about their personal experience, and how it relates to 15 mine. It's a way of exchanging ideas and staying up on 16 the latest interventions. 12:34P 17 Q. The one pharmaceutical company, Bristol-Myers Squibb, what 18 was the other company? 19 A. Otsuka. 20 Q. How do you spell that? 21 A. O-t-s-u-k-a. 22 Q. Is that an United States company? 23 A. It is a co-promoter of a new drug called Abilify with 24 Bristol-Myers Squibb. 25 Q. What kind of drug is Abilify? 15 1 A. Abilify is the newest antipsychotic medication available. 12:35P 2 Q. What class is it in, do you know? 3 A. Antipsychotic. 4 Q. You know, in Detroit they have these big meetings where 5 you can go to get continuing education credits. Is that 6 what you're describing with these pharmacy meetings you've 7 had? 8 A. These are not CME accredited meetings. These are dinner 9 meetings or luncheon meetings. 10 Q. And you're the presenter at these dinner or luncheon 11 meetings for the drug company? 12 A. I am the expert. 13 Q. Who are the participants or audience at these dinners and 14 luncheons? 15 A. Usually it's between four and ten people. The pharmacy 16 company pays for dinner and the members of the party sit 17 around and discuss cases and their experiences with 18 various medications. Often we go off topic. As a speaker 19 representing the company, unless a specific question is 20 asked, I'm not allowed to speak on anything off label from 21 the FDA, but I can answer a question given to me. 12:36P 22 Q. When you say off label from the FDA, are you saying 23 whatever is in the PDR for that moment in time is the only 24 thing you're supposed to be chatting about? 25 A. It's the only thing that I can directly present but can 16 1 respond to any questions asked. 2 Q. Are you paid by the drug companies to sit at those 3 dinners? 4 A. Yes, ma'am. 5 Q. How much are you paid? 6 A. Depending on what company I'm speaking for and the area 7 I'm speaking in and the number I do in that particular 8 day, it ranges from a thousand dollars to five hundred 9 dollars. 10 Q. Were you ever involved in one of these luncheons and 11 dinners with regard to the drug Risperdal? 12 A. Yes, ma'am. 13 Q. How long ago? 14 A. Referring to my C.V., I have been talking for Janssen 15 Pharmaceutical, the maker of Risperdal, since December 4, 16 2000. 12:37P 17 Q. Do they provide you with information surrounding -- strike 18 that. Does the drug company provide you with information 19 prior to your lunch or dinner meeting to discuss that 20 specific drug? 21 A. Prior to going on the speaker's bureau for any 22 pharmaceutical company, one must go through speaker 23 training which is usually a weekend in some nice place 24 where you get the latest research. Often you're provided 25 with additional materials to review should you choose to 17 1 and back in 2000, I believe there was even a slide 2 presentation given to the various speakers. 12:38P 3 Q. Did you receive a slide presentation back in year 2000 4 from Janssen Pharmaceuticals? 5 A. Yes, ma'am. 6 Q. Do you have that slide presentation on Risperdal? 7 A. Given that I am a pack rat I probably do. 8 Q. Well, you're in good company. Do you have any objection 9 to me asking your attorney to provide me with copies of 10 that slide presentation and any materials you were 11 provided by Janssen with regard to Risperdal? 12 A. It is proprietary information and, therefore, I wouldn't 13 be allowed to give it out. 14 Q. Proprietary on whose behalf? 15 A. Janssen Pharmaceutical, the maker of Risperdal. I have to 16 sign a contract saying it belongs to them. You could 17 request it from them. 12:39P 18 Q. Is that true, that contract that you have to sign with 19 regard to proprietary information, is it true with regard 20 to all the pharmaceutical companies you work with? 21 A. Yes, ma'am. 22 Q. What is the purpose of that to your knowledge? 23 MR. GANO: What's the relevance of any of this? 24 MS. TUREK: That's your objection? 25 MR. GANO: Yes. I am going to object to lack of 18 1 relevance. Are we going to talk about -- okay. Go ahead. 2 MS. TUREK: You can have a standing objection to 3 relevance according to the court rule. 4 Q. (MS. TUREK) Go ahead. 5 A. Would you repeat the question? 6 MS. TUREK: Sure. Reatha, would you read it 7 back? 12:40P 8 (Record read as follows: 9 1 Q. Is that true that contract that you have to 10 sign with regard to proprietary information, is 11 it true with regard to all the pharmaceutical 12 companies you work with? 13 THE WITNESS: Yes.) 14 Q. (MS. TUREK) And to your knowledge why is there a contract 15 such as that with regard to protecting the proprietary 16 information? 17 MR. GANO: Objection to foundation. 18 MS. TUREK: It's to her knowledge. 19 THE WITNESS: I'm not part of their marketing 20 plan. I either agree to the terms and speak for them or I 21 don't agree to the terms and don't speak for them. 22 Q. (MS. TUREK) Did you ever speak on behalf of a 23 pharmaceutical company that manufactures the drug 24 Seroquel? 12:41P 25 A. No. 19 1 Q. Do you know who manufactures Seroquel? 12:42P 2 A. I believe it's AstraZeneca. 3 Q. Is there a generic for Seroquel now? 4 A. No, ma'am. 5 Q. That means there wasn't a generic for Seroquel back in 6 2000, right? 7 A. That's correct. 8 Q. That's because it's a relatively new medication, right? 9 A. Correct. 10 Q. What about Celexa, did you ever speak on behalf of the 11 manufacturer of Celexa? 12 A. No, ma'am. 13 Q. Is there a generic name for Celexa? 14 A. Citalopram. 15 Q. Is there a generic brand of Citalopram? 16 A. That is the generic. Citalopram is the generic. 17 Q. Is there a generic brand? 18 A. Brand or generic? 19 Q. Right. Celexa is the trade name for a certain brand, 20 right? 12:43P 21 A. The brand name is Celexa. 22 Q. Correct. Is there a generic brand for Citalopram? 23 A. No. 24 Q. Because Celexa is also a newer drug, right? 25 MR. GANO: Wait a minute. Are you asking is it 20 1 a newer drug or is it not a generic because it's a newer 2 drug, which? 3 MS. TUREK: That's the question. 4 MR. GANO: There's no generic, just... 5 MS. TUREK: Right. Yes. 6 MR. GANO: I mean we know it's a newer drug. 7 She has already said that, right, I think? 8 THE WITNESS: (Shaking head side to side.) 9 MR. GANO: No? Okay. That's why I'm confused 10 about the compound nature of the question, whether it's a 11 new drug or is it a drug that has no generic. 12 MS. TUREK: Okay. 13 Q. (MS. TUREK) Does Celexa -- is Citalopram manufactured by 14 anyone else other than the Celexa manufacturer? 15 A. Yes. 16 Q. Who? 17 A. I don't know who manufactures the generic. 12:44P 18 Q. All right. Have you ever made a presentation on behalf of 19 the brand -- I beg your pardon -- the generic manufacturer 20 of Citalopram? 21 A. No. 22 Q. So the only presentations you have ever provided with 23 regard to any of the medications that were provided to 24 Christopher Morden while he was in jail was Risperdal, 25 right? 21 1 MR. GANO: Well, I object. I don't know if she 2 knows any of the medications. If you want to say any of 3 the antipsychotic medications, based upon that -- 4 MS. TUREK: Sure. What's the objection then, 5 the legal objection? 6 MR. GANO: My objection is to form and 7 foundation. 8 MS. TUREK: Sure. 12:45P 9 THE WITNESS: Would you mind repeating the 10 question? 11 Q. (MS. TUREK) Not a bit. Let me try again then. You know 12 that Christopher Morden was provided with Risperdal, 13 Seroquel, and Celexa in jail, right? 14 A. Yes, ma'am. 15 Q. Out of those three medications, Risperdal is the only 16 medication that you have ever provided presentations to? 17 Okay. That was bad, wasn't it? 18 A. I understand the question. 19 Q. Thank you. Go ahead. 20 A. No. 21 Q. You have presented presentations on either Seroquel and/or 22 Celexa? 23 A. I have spoken about both of those drugs in some 24 presentations. They may not have been sponsored by those 25 drugs companies, but I have spoken about those drugs. 22 1 Q. Thank you. If I look at your C.V. that was provided to 2 me, we know that there are twelve presentations that are 3 not on the C.V. which should be on there to bring it 4 up-to-date and current? 12:46P 5 A. That I can recall. 6 Q. Sure. Are there any other changes that you would make to 7 the C.V. to bring it up-to-date and current? You have the 8 same one I do if it's attached. 9 A. Okay. Great. 10 Q. Take your time looking through that. 11 A. The only addition has been to my education in which I have 12 recently sat for board certification for clinical 13 psychopharmacology. 14 MS. LYNN: Clinical what? 15 THE WITNESS: Psychopharmacology. 16 MS. LYNN: Thank you. 17 Q. (MS. TUREK) Did you have to endure further education to 18 get to that spot? 19 A. Life is further education. 20 Q. Okay. How about formal education? 21 A. Yes. I have read additional materials and books and felt 22 ready this year to undertake that board certification. 12:47P 23 Q. When did you begin studying for the clinical 24 psychopharmacology? 25 MS. LYNN: Cerification? 23 1 MS. TUREK: I'm sorry? 2 MS. LYNN: I'm just asking is the question when 3 did she start studying for the certification? 4 MS. TUREK: For clinical psychopharmacology. 5 THE WITNESS: I have studied clinical 6 psychopharmacology since entering residency in psychiatry 7 in 1998. 8 Q. (MS. TUREK) You entered your residency in 1998? 9 A. Yes, ma'am. Sorry 1994. My apologies. Sorry I can't 10 read my own -- I should put my glasses on. There we go. 12:49P 11 Q. When did you sit for the boards or you already did? 12 A. Yes, two weeks ago. 13 Q. When do you find out? 14 A. They give you an immediate response at that time. 15 Q. And what? 16 A. It's not official, but I have a board certification in 17 clinical psychopharmacology. It's not official, however. 18 Q. Your bachelor's of arts is in what area? 19 A. Good Lord. I majored in psychology, minored in organic 20 chemistry and sociology. 21 Q. What did you do after your bachelor's of arts 22 professionally? I notice you graduated in 1976 and there 23 is nothing under professional experience between 1976 and 24 1991? 12:50P 25 A. Right. University of Michigan as a research associate in 24 1 various research labs. 2 Q. Were they psychological research labs? 3 A. One was in the neural sciences with Dr. Leslie Rutledge 4 who has since passed away. One was with Stevo Julius in 5 hypertension. Another one was with Dr. Bertram Pitt in 6 cardiac surgery in the animal preparations. 7 Q. When did you start working on your bachelor's of science 8 at the University of South Alabama? 9 A. 1981. 12:51P 10 Q. So from 1976 until to 1981 you were a research assistant? 11 A. An associate working my way up the scale. 12 Q. Your Bachelor's of Science from the University of South 13 Alabama, what subject? 14 A. Basic medical sciences. 15 Q. Did you know you were going to med school then? 16 A. (Nodding head up and down.) 17 Q. And your M.S., is that a Master's of Science from the 18 University of Michigan? 19 A. Uh-huh. Yes, ma'am. 20 Q. From the University of Michigan School of Public Health? 21 A. Yes, ma'am. 22 Q. What is that? 23 A. Clinical research, design, and statistical analysis. 24 Q. And what kinds of things did you clinically research, 25 analyze, and design? 25 1 A. I was the recipient of a 1.1 million dollar grant through 2 NIMH to study premenstrual syndrome. 3 Q. Off the record. 4 (Off-the-record discussion.) 12:52P 5 Q. (MS. TUREK) The PhD from the University of Michigan 6 Rackham Graduate School, what did you obtain your PhD in? 7 A. Physiology specializing in reproductive intracrinology. 8 Q. And your M.D. from Michigan State University? 9 A. Yes, ma'am. 10 Q. And you chose to go into psychiatry, right? 11 A. After a six-month stint in internal medicine in Nepal. 12 Q. And what was the second part of what you said? 13 A. In Nepal. 14 Q. Okay. Wow. Is that volunteer? 15 A. Yes, ma'am. 16 Q. You completed your residency or your psychiatry residency 17 in 1997, right? 12:53P 18 A. 1998. It's a four- or five-year program depending. 19 Q. Did you do all of your residency at the Sheppard Pratt 20 Health System? 21 A. Under the direction of the Sheppard Pratt Health System, 22 doing residency requires you to be at other hospitals. 23 Q. You were raised in Michigan? 24 A. Yes, ma'am. 25 Q. Were you raised in this neck of the woods? 26 1 A. My grandmother. 2 Q. Where were you raised, in what part of Michigan? 3 A. Sometimes up here but mostly in Worcester, Massachusetts; 4 Boylston, Massachusetts; New Orleans. My father worked 5 for the government. We moved a lot. 12:54P 6 Q. And right out of your residency you came to Munson Medical 7 Center? 8 A. I actually came to Great Lakes Community Mental Health as 9 an outpatient psychiatrist and for Great Lakes Community 10 Mental Health worked in the inpatient unit at Munson 11 Medical Center. 12 Q. What year were you board certified in psychiatry? 12:55P 13 A. I would have to get that to you. 14 Q. That's prior to 2000 you were board certified in 15 psychiatry? 16 A. I would have to get that to you. I'm not clear as to the 17 date. 18 Q. You're board certified? 19 A. Yes, ma'am. 20 Q. You passed on the first try? 21 A. No, I did not. 22 Q. How many tries? 23 A. I believe it was two. 24 Q. And which part didn't you pass the first time? 25 A. It was the live interviews. 27 1 Q. And Great Lakes Community Mental Health, is that the same 2 as -- what's the name of it? -- Northern Lakes Community 3 Mental Health Authority? 4 A. Yes, ma'am. 5 Q. Is that the same organization? 6 A. Yes, ma'am. 7 Q. Did you ever stop your association with Northern Lakes 8 Community Mental Health Authority? 12:56P 9 A. No, ma'am. 10 Q. You're still associated with that group? 11 A. As a contract physician. 12 Q. And what does that mean as a contract physician? 13 A. I get paid for the hours that I work for them. 14 Q. Do you have a contract with Northern Lakes Community 15 Mental Health Authority? 16 A. Yes, ma'am. 17 Q. When was that contract signed? 18 A. I believe I sign one whenever it comes due. 19 Q. Oh, it's not something that's in place forever. You have 20 to renew the contract now and then? 21 A. Correct. 22 Q. I'm going to ask your attorney to provide that to me. 23 MS. TUREK: Do you have any objections to that? 24 MR. GANO: I don't know -- I mean I'll have to 25 look at it. I haven't seen it. What year do you want 28 1 this contract for? 2 MS. TUREK: For the time period -- 3 MR. GANO: For the year 2002 -- 4 MS. TUREK: Right. 5 MR. GANO: -- which would have covered the time 6 span in which she was involved in providing consulting 7 services to Christopher Morden. 12:57P 8 MS. TUREK: Yes, sir. 9 MR. GANO: Okay. 10 Q. (MS. TUREK) And do you have a contract between yourself 11 and the Grand Traverse County jail? 12 A. No, ma'am. 13 Q. How is it then that you render services to inmates at the 14 Grand Traverse County Jail? 15 A. I do it under the auspices of Northern Lakes Community 16 Mental Health. 17 Q. In your corporation, this Well-Spring Psychiatry -- 18 A. Yes, ma'am. 19 Q. -- where did you get the name for that? Is it from a city 20 or something? 21 A. We put five options on the board on the unit and everybody 22 voted and that's the one that went. 23 Q. What unit? 24 A. Central One Unit, the inpatient psych unit. 25 Q. Is Well-Spring Psychiatry just your -- 29 1 A. Just me. 2 Q. -- professional corporation? 3 A. Just me. 12:58P 4 Q. And you had input from staff at Munson Medical Center with 5 regard to the name of the organization? 6 A. Yes. 7 Q. Munson is not a parent corporation? 8 A. No, ma'am. 9 Q. It's just you by yourself according to your Answers to 10 Interrogatories, correct? 11 A. Yes, ma'am. 12 Q. How long has Well-Spring been in place? 13 A. Ever since the lawyer told me I needed to do it that way. 14 Q. When was that? 15 A. Probably shortly after I arrived in town which would have 16 been like '98, '99, something like that. 17 Q. Are there any other psychiatrists at Northern Lakes 18 Community that provides services to inmates? 19 A. I don't know the answer to that question. Oh, 2000 it was 20 started. Sorry. 12:59P 21 Q. What month? 22 A. May. 23 Q. And while we're on that, does Northern Lakes Community 24 Mental Health Authority provide you with malpractice 25 liability coverage? 30 1 A. No. I'm a contract physician. 2 Q. Do you let the inmates that you treat know that you're a 3 contract physician? 4 A. No, ma'am. 5 Q. The inmates would have no way of knowing that you're a 6 contract physician, right? 7 A. I have no knowledge of what the inmates know. 8 Q. You didn't, with Christopher Morden for instance, you 9 didn't let him know that you were an agent of Northern 10 Lakes Community Mental Health Authority, right? 11 MR. GANO: Well, I'll object to the form of the 12 question. It calls for a legal conclusion. 13 MS. DEBLER: And foundation. 14 Q. (MS. TUREK) Did you ever have a discussion with 15 Christopher Morden in which you informed him that you were 16 a contract physician through Northern Lakes Community 17 Mental Health Authority? 1:00P 18 A. Not to my knowledge. 19 Q. Did you ever tell Christopher Morden that you were a 20 contract physician through the Grand Traverse County Jail? 21 A. Not to my knowledge. 22 Q. You would agree that it would be reasonable for 23 Christopher Morden to think that the jail provided you to 24 him? 25 MR. GANO: I'll object to the form of the 31 1 question. It calls for speculation as to the state of 2 mind of another individual. 3 MR. WIERDA: I'll join. Also, foundation. 4 Q. (MS. TUREK) Did you ever provide any information to 5 Christopher Morden that you were not an agent of the Grand 6 Traverse County Jail? 7 A. We never discussed anything about that. 8 Q. And you treated Christopher Morden only at the jail, 9 right? 10 A. Yes, ma'am. 11 Q. You never had a relationship with Christopher Morden prior 12 to the first time you laid eyes on him in Grand Traverse 13 County Jail, correct? 1:01P 14 A. Correct. 15 Q. You're the Medical Director of the Behavorial Health Unit 16 at Munson Medical Center, right? 17 A. Yes, ma'am. 18 Q. Who was the prior medical director of the Behavorial 19 Health Unit at Munson? 20 A. Dr. Martin Vandenakker. 21 Q. Where did Dr. Martin Vandenakker go, if you know? 22 A. He's now employed part time with the Veterans 23 Administration in town as their staff psychiatrist as well 24 as a contract physician for Northern Lakes Community 25 Mental Health. 32 1 Q. And you're still an assistant professor of Michigan State 2 University? 3 A. That is correct. 4 Q. Is that why the student is here with us today, she is one 5 of your students? 6 A. Yes, ma'am. 7 Q. Are you paid by Michigan State University to be a 8 professor? 1:02P 9 A. I'm unclear as to the fiduciary intricacies with regard to 10 Munson and Michigan State, but in my contract with Munson 11 I'm obligated to teach medical students and residents. 12 Q. How long have you been obligated to teach medical students 13 and residents? 14 A. My contract with Munson Medical Center started when I 15 became the medical director. 16 Q. Prior to you becoming the medical director, did you have a 17 contract with Munson Medical Center? 18 A. No, ma'am. 19 Q. From 2001 to the present, your C.V. states that you were 20 preceptor for Munson Health Care Family Practice program. 21 What is that? 22 A. Mondays from 2:00 to 4:00, I sit in a preceptor room and 23 impart wisdom to residents about the patients they are 24 seeing. 1:03P 25 Q. Are these psychiatry patients? 33 1 A. These are family practice patients in their family 2 practice clinic. 3 Q. So it doesn't have anything to do -- this precepting 4 doesn't have anything to do with psychiatry? 5 A. Sixty-five percent of the patients walking into the family 6 practice clinic have some sort of psychiatric malady of 7 which I coach them on how to best deal with that. 8 Q. Is that true for the general population, that statistic? 9 A. I wouldn't know that. 10 MS. LYNN: I'm sorry. I didn't hear the answer. 11 THE WITNESS: I wouldn't know that. 12 MS. LYNN: Thank you. 13 Q. (MS. TUREK) How did you arrive at the sixty-five percent 14 with psychiatric problems? 15 A. I believe that was a number given to me when I was in 16 psychiatric residency training. 17 Q. That every ill patient that walks in a family practice 18 clinic or any medical building? 19 A. I believe it was in regards to the general practice which 20 could consist of internal medicine, pediatrics, or family 21 practice. 1:04P 22 Q. And what is the Physician Advisory Committee for 23 Integrated Medicine? 24 A. Integrated medicine is an attempt at Munson to bring in 25 other modalities to assist with patients such as herbals, 34 1 massage, music therapy. There are a number of physicians 2 who have agreed to sit on this committee and advise Munson 3 as to other modalities that are available. There is a 4 medical director for this by the name of Katherine Roth 5 who practices in this community. 6 Q. And the Medical Director of Grand Traverse Depressive and 7 Manic-Depressive Association, is that a group of patients 8 that you direct? 1:05P 9 A. Yes, ma'am. I'm the actual physician advisor for that 10 group. 11 Q. And it's a group of patients, right? 12 A. Yes, ma'am. 13 Q. You don't have a physician-patient relationship with those 14 folks, do you? 15 A. No. I'm a physician advisor to that self-help support 16 group. 17 Q. And is that a volunteer position that you hold with that 18 group? 19 A. Yes. They approached me and I agreed to be their 20 physician advisor as every group for the national 21 association needs to have a physician advisor associated 22 with them. 1:06P 23 Q. The Clinical Assistant Professor at Michigan State 24 Colleges of Human Medicine and College of Osteopathic 25 Medicine, you're two kinds of professor for Michigan 35 1 State, right? 2 A. That is an introductory position and I have since risen 3 to -- you will notice that's a clinical assistant 4 professor. I'm now an assistant professor. 5 Q. So that 1998 to the present, that would or should read 6 1998 to 2002? 7 A. Yes, ma'am, it should. There you go. Thank you. I will 8 make that change. 9 Q. Psychiatric consultant to Grand Traverse Correctional 10 Facility, 1998 to the present. You had testified earlier 11 that the only reason you're associated with the Grand 12 Traverse was through the Community Mental Health 13 Authority, right? 14 A. Yes, ma'am. 15 Q. Generally speaking, since 1998 how is it you become 16 involved in a specific inmate's care? 1:08P 17 A. I receive a request from the jail workers at what's now 18 called Northern Lakes Community Mental Health. A schedule 19 is given to me and I see those patients and handwrite out 20 a list, return it to whoever is covering the jail that 21 day, then I believe copies are made for the patient's file 22 as well Dr. Wilcox and I believe a copy goes to the 23 transcriptionist at Northern Lakes Community Mental Health 24 so that it can be transcribed in English rather than my 25 shorthand. 36 1 Q. To your knowledge your handwritten notes then should be 2 part of the medical record, right? 1:09P 3 MR. GANO: What medical record; Great Lakes 4 Community Mental Health, the jail's record? 5 Q. (MS. TUREK) The jail record. 6 A. I have no knowledge of where it goes after that. 7 Q. When you make notes on an inmate's -- strike that. When 8 you have made notes on an inmate's medical care and 9 treatment, did you just say that you first write down 10 notes, then you give them to the Community Mental Health 11 authority, and then they are transcribed? 12 A. They get my handwritten copy, yes. 13 Q. Who gets your handwritten copy? 14 A. Whoever is covering the jail that day. 15 Q. So you actually hand a handwritten copy of your notes on a 16 specific patient to someone in the jail, right? 17 A. To the Northern Lakes Community Mental Health worker. 18 Q. Is there a Northern Lakes Community Mental Health worker 19 assigned to the jail every single day? 20 A. I do not know that. 21 Q. Has there ever been a time when you've written a note on a 22 patient and not handed it to a Community Mental Health 23 worker? 1:10P 24 A. Yes. 25 Q. Is there ever a time that you made notes on Christopher 37 1 Morden and did not hand them to a Community Mental Health 2 worker? 3 A. I don't recall. 4 Q. How do you know that there are times when you didn't hand 5 your notes to a Community Mental Health worker? 6 A. On occasion I've been given a list and a Community Mental 7 Health worker has not been available to accompany me to do 8 my Tuesday from 8:00 to 10:00. 9 Q. That's Tuesday from 8:00 a.m. to 10:00 a.m.? 10 A. Yes, ma'am. 11 Q. Have you been doing Tuesdays from 8:00 a.m. until 10:00 12 a.m. since you started at the jail? 13 A. I currently am not doing that. 14 Q. When did you stop providing services to inmates at the 15 Grand Traverse County Jail? 16 A. I think October of last year. 1:11P 17 Q. It would be October of 2004? 18 A. I believe so, but I would have to check my records to 19 confirm that. 20 Q. Why did you stop providing services to inmates at Grand 21 Traverse jail? 22 A. The position was no longer funded. 23 Q. To your knowledge who made the decision not to fund 24 psychiatric patients at the jail? 25 A. I don't know. 38 1 Q. You might want to change your C.V. You have 1998 to the 2 present there also with regard to the consulting at the 3 Grand Traverse County Jail. 4 A. Well, I'm still available to them should they call. 5 Q. You would not be paid for that visit if they call, is that 6 right? 7 A. That's correct. 8 Q. Are you still associated with the Northern Lakes Community 9 Menal Health Authority? 10 A. I'm a contract physician. 11 Q. Still to this day? 12 A. (Nodding head up and down.) 13 Q. Okay. So you just stopped -- is that yes? 14 A. Yes, ma'am. 15 Q. So you just stopped at the Grand Traverse County Jail? 1:12P 16 A. Yes, ma'am. 17 Q. With regard to your presentations, you have quite a few 18 that are titled Antipsychotic Efficacy Uncompromised by 19 Side Effects, right? 20 A. There are a number of them with that title, yes. 21 Q. Was each of these or were each of these presentations with 22 regard to a specific medication or was it a broad -- 23 A. As indicated, it's antipsychotics. 24 Q. So it was all antipsychotics you made each one of these 25 presentations? 39 1 A. Yes, ma'am. 2 Q. Who manufactures Rispirdal? I'm sorry. 1:13P 3 A. Janssen Pharmaceutical -- 4 Q. Janssen? 5 A. Janssen Pharmaceutical. 6 Q. Thank you. Did you include Risperdal in any of the 7 presentations that you have ever made? 8 MR. GANO: Presentations that she's ever made on 9 antipsychotics, any presentations? Sorry. I object to 10 the form of the question. 11 THE WITNESS: It seems very general to me. 12 Q. (MS. TUREK) Did you ever include Risperdal -- 13 A. In what? 14 Q. -- in your topic on Antipsychotic Efficacy Uncompromised 15 by Side Effects? 16 A. Yes, ma'am. 17 Q. You're well aware of all of the side effects of Risperdal, 18 right? 19 A. I'm aware of the usual side effects associated with most 20 of the antipsychotic medications. 21 Q. You would agree the standard of care requires you to be 22 familiar with the side effects of any of the drugs that 23 you prescribe, right? 1:14P 24 A. Yes, ma'am. 25 Q. In this Antipsychotic Efficacy Uncompromised by Side 40 1 Effects -- do you need a break? 2 MR. GANO: No. I just took a contact lens out. 3 It was scratching my eye. 4 MS. TUREK: Oh, okay. 5 Q. (MS. TUREK) This Antipsychotic Efficacy Uncompromised by 6 Side Effects, these presentations you made on the same -- 7 it's like a risk benefit analysis? 8 A. Yes, it is. There are no medications that do not have 9 some side effects associated with them. 10 Q. You would agree that some side effects are 11 life-threatening if not recognized in a timely manner? 12 A. Yes, ma'am. 13 Q. Death is one of those side effects of an antipsychotic, 14 right? 15 A. Yes, ma'am. 1:15P 16 Q. And you'd agree that antipsychotics administered with 17 psychotropics may increase the potential for -- okay. 18 Thank you. Is a psychotropic the same as an 19 antipsychotic? 20 A. Psychotropic is a general term referring to 21 antipsychotics, antidepressants, anxiolytics, et cetera. 22 Q. So psychotropic medications would be the heading and all 23 those other agents that you just listed or classes that 24 you just listed are subsets of psychotropics, right? 25 A. Yes. 41 1 Q. A psychotropic is any drug that's given -- 2 A. That affects the CNS. 1:16P 3 Q. Thank you. Did you ever give a presentation -- strike 4 that. Do you have handouts for any of these presentations 5 that you made other than the ones that aren't protected by 6 the pharmaceutical company's proprietary contract? 7 A. Yes. 8 Q. Which presentations do you have handouts that are not 9 protected by the proprietary contract? 10 A. I actually have a set of slides that I personally put 11 together illustrating many of the side effects typically 12 encountered in prescribing these medications. I have a 13 number of slide presentations actually, probably in the 14 thousands of slides. 15 Q. Would each of these slides be dated somehow? 16 A. The majority of them, not. 17 Q. You would be able to tell by looking at the slides the 18 approximate time period within which you used those slides 19 at a presentation, right? 4:56P 20 A. Yes, ma'am. 21 Q. Do you have any objection to your attorney providing 22 copies of those slides to me or even better your attorney 23 and I and you and without you saying anything could sit in 24 a room and look at the slides just like we did today with 25 the photographs? Would that be okay? 42 1 MR. GANO: I'd have to go over them with her 2 first. We would have to have some agreement as to their 3 use and the expense of reproducing them including the 4 doctor's time in spending whatever hours it would take to 5 go through those, yes, but we can talk about that. 6 MS. TUREK: I'll also do a motion to come on the 7 land. All I want to do is look at them. 8 MR. GANO: I mean I'm happy to talk about it. I 9 don't know what they are. I haven't seen them. I can't 10 give you an understanding or a promise or a commitment as 11 to anything -- 12 MS. TUREK: Sure. 13 MR. GANO: -- until I have seen that and then we 14 can talk about it. And if I can't do it voluntarily, you 15 ask always obtain an appropriate court order. 1:18P 16 MS. TUREK: Sure. What do you need from me? 17 Just like the conversation that we had yesterday that 18 whatever makes it easier on you, that type of thing, what 19 do you need from me so that I can follow-up? 20 MR. GANO: I need you to tell me what it is you 21 want to see, from what time span you want to see it, and 22 what you intend to use it for. 23 MS. TUREK: Okay. We can take a break any time 24 you want? You know that, right? 25 THE WITNESS: I'm just thinking of the copious 43 1 amount of slides I have. 2 MS. TUREK: What I'm thinking about here, too, 3 just to shorten this up is we could look at them and the 4 ones that interest me -- I would only want to see the ones 5 up to the date that Christopher died which is April 1, 6 2002 and then I would ask what are these from that time 7 period. How about that? That would narrow it down just a 8 little bit. 1:19P 9 MR. GANO: Send me a letter, send me a request, 10 or however you want to do it and we'll cooperate anyway we 11 can. 12 MS. TUREK: Thank you sir. 13 Q. (MS. TUREK) These abstracts, did you ever write anything 14 on psychotropic medications? 15 A. I have written a lot of things, but I don't believe 16 anything has been published on psychotropic medications. 17 Q. Do you have anything that you're preparing to publish or 18 intend to publish on psychotropic medications? 19 A. There is something I'm thinking about writing up. 20 Q. What is that? 21 A. The effects of psychotropics in ECT on a patient with 22 autonomic instability secondary to a DHE overdose. 1:20P 23 Q. So that was one patient that you encountered that you 24 would be writing a paper on? 25 A. I'm in discussions with other members of the Munson 44 1 faculty about preparing such a paper. It's way cool. 2 Q. It sounds cool. 3 A. There is nothing else in the literature on it. 4 Q. In your publications and abstracts, you're familiar with 5 cardiac arrhythmia, right? 6 A. Yes, ma'am. 7 Q. Dysrhythmia, same thing, right? 8 A. Arrhythmia and dysrhythmia, yes. Subtle differences. 9 Q. Have your privileges at any hospital or organization ever 10 been limited? 1:21P 11 A. No, ma'am. 12 Q. Have they ever been suspended? 13 A. No, ma'am. 14 Q. Have they ever been denied? 15 A. No, ma'am. 16 Q. Have they ever been revoked? 17 A. No, ma'am. 18 Q. Have you ever had a disciplinarian action by any 19 institution? 20 A. No, ma'am? 21 Q. And we already know about all the administrative positions 22 you hold, right, or held? 23 A. I don't know what you know. 24 Q. Oh, oh, I'm sorry. That was a good one. Are there any 25 other administrative positions that we have not talked 45 1 about thus far? 2 MR. GANO: Do you mean not contained within her 3 C.V. for which you have asked her specific questions. 4 MS. TUREK: Right. Thank you. 5 THE WITNESS: Correct. 6 Q. (MS. TUREK) And this clinical psychopharmacology -- did I 7 say it right? 8 A. Yes, ma'am. 9 Q. Okay. This is the first time you have taken the exam, a 10 couple weeks ago, right? 11 A. Yes, ma'am. 1:22P 12 Q. You render only care and treatment as a psychiatrist, 13 right? 14 A. Yes, ma'am. 15 Q. And because you're an M.D. as well, you take into account 16 the whole patient, right? 17 A. Yes, ma'am. 18 Q. And you would agree the standard of care requires that 19 even if there is another doctor caring for the patient 20 that the psychiatrist should take into account the whole 21 patient, right? 22 A. Yes, ma'am. 23 Q. When the Grand Traverse County Jail funded your visits to 24 inmates, were you paid by the hour or were you paid per 25 patient? 46 1 A. The Grand Traverse Jail to my knowledge has never funded a 2 psychiatrist. 3 Q. Oh. So the funding that was just eliminated was through 4 Northern Lakes? 5 A. Yes, ma'am. 6 Q. And do you have any idea -- you already said you don't 7 know why it was stopped -- hum. Do you render care at 8 places other than the Grand Tranverse County Jail for 9 Northern Lakes? 1:23P 10 A. Yes, ma'am. 11 Q. Where? 12 A. Munson Medical Center. 13 MS. LYNN: You said Munson Medical Center? 14 THE WITNESS: Munson Medical Center. 15 Q. (MS. TUREK) Anywhere else? 16 A. Ever? 17 Q. Sure. Through Northern Lakes Community Mental Health. 18 A. Yes. When I worked for Northern Lakes Community Mental 19 Health prior to working for Munson Medical Center, I also 20 saw patients at nursing homes. 21 Q. Do you still see patients at nursing homes? 22 A. Not for Northern Lakes Community Mental Health. 23 Q. For your own corporation? 24 A. Yes, ma'am. 25 Q. Do you know what a kite is? 47 1 A. Yes, ma'am. 2 Q. What is that? 3 A. It is a slip generated by an inmate or another personnel 4 at the jail with a request. 1:24P 5 Q. Did you have see any kites for Christopher Morden? 6 A. I know that there were some, but I cannot recall ever 7 having seen the actual kite. 8 Q. Is a kite something that you would have written upon, 9 also? 10 A. No, ma'am. 11 Q. The kite is something that was generated by someone else 12 and provided to you? 13 A. It's provided to the nurse, the doctor, the correctional 14 officer, Community Mental Health. They are almost never 15 directed towards me specifically. 16 Q. What's the purpose of the kite to your knowledge? 17 A. To get some attention for something. 18 Q. So, again, it wasn't your experience that a kite would 19 actually be held in your hand and examined on behalf of a 20 patient? 1:25P 21 A. I cannot emphatically say that I have never held a kite in 22 my hand. 23 Q. But most of the time a kite is not something you 24 encounter, right? 25 A. Right. 48 1 Q. Gotcha. There is like a chain of events that occurs prior 2 to you even laying eyes on the inmate, right? 3 A. Yes, ma'am. 4 MR. WIERDA: Objection to foundation. 5 Q. (MS. TUREK) To your knowledge, what is that chain of 6 events? 7 MR. WIERDA: Same objection. 8 THE WITNESS: That somehow it comes to the 9 attention of the CMH worker that a patient is in need of a 10 psychiatric assessment. How that information reaches the 11 CMH worker comes from various sources. 12 Q. (MS. TUREK) And to your knowledge, would the jail 13 physician -- Dr. Wilcox is the jail physician, right? 1:27P 14 A. Yes. 15 Q. He has been the jail physician for how long to your 16 knowledge? 17 A. I have no idea. 18 Q. He has been the jail physician for as long as you've been 19 going to Grand Traverse County Jail? 20 A. That's correct. 21 Q. To your knowledge, would the jail physician complete a 22 kite so you would see a patient? 23 A. I really don't know. 24 Q. Okay. You have never encountered a kite that has been 25 authored by Dr. Wilcox, right? 49 1 A. Not that I can recall. 2 Q. In Christopher Morden's case, who called you in or called 3 you to care for Christopher Morden? 4 A. To the best I can recall, Anne Baase requested that I 5 render services to him. Follow-up was given to me at the 6 time sequences that I specified. He showed up on my list 7 of patients to see that day which may have been given to 8 me by Mr. Karlin or it may have been given to me by Ms. 9 Baase or it may have just been left for me to do. 1:28P 10 Q. And with regard to Christopher Morden, once you 11 encountered him, were you permitted to direct his 12 psychiatric care with regard to the frequency of visits? 13 A. I only make recommendations and ask for consideration. 14 It's my understanding per the request of CMH that I not 15 directly write medications for patients or make any 16 medical interventions but instead consult with the jail 17 physician regarding what might be appropriate care for 18 him. 19 Q. You would agree that you as a psychiatrist are in a better 20 position to determine the appropriate care with regard to 21 the prescription of psychotropic agents, right? 1:29P 22 A. As opposed to whom? 23 Q. As opposed to a jail physician. 24 A. I would imagine it would have to do with what the 25 knowledge base of the jail physician was. 50 1 Q. Is that something that you assess prior to prescribing 2 psychotropic medications to an inmate? 3 A. The jail physician's knowledge base, no, ma'am. 4 Q. You trust that the jail physician knows as much as you do 5 about psychotropic medications? 6 A. I have no knowledge of what the jail physician knows or 7 does not know. I presume he does his job appropriately or 8 he wouldn't be the jail physician. 9 Q. You said there is a Community Mental Health, that's 10 Northern Lakes Community, right, when you say Community 11 Mental Health? 12 A. At the time of the sentinel event, I believe it was called 13 Great Lakes but currently is Norther Lakes. 14 Q. Okay. So how about let's agree here every time you or I 15 use the phrase Community Mental Health, we're talking 16 about Northern Lakes Community Mental Health Authority, 17 formerly known as Great lakes Community Mental Health? 1:30P 18 A. Yes, ma'am. 19 Q. There is no other one out there that we know of, right? 20 A. Yes, ma'am. 21 MR. WIERDA: Just for clarification, there's 22 Antrim Kalkaska Community Mental Health and I think we've 23 already discussed there's some records for that. 24 MS. TUREK: Okay. 25 Q. (MS. TUREK) Are you associated with Antrim County 51 1 Community Mental Health? 2 A. No, ma'am. That's now called North Country Mental Health. 3 Q. Okay. So the only one you have ever been associated with 4 is Northern Lakes Community Mental Health Authority, 5 formerly known as -- I'm sorry. 6 A. Great Lakes. 7 Q. -- Great Lakes Community Mental Health? 8 A. Yes, ma'am 9 MR. WIERDA: Which merged with North Central 10 Community Mental Health. 11 MS. TUREK: Quit it. 12 THE WITNESS: And it is now considered the 13 southern counties. 14 MR. GANO: Enough to make you crazy? 15 MS. TUREK: Yeah, kind of. If Brad knows it, 16 I'm going to know it, though. 17 Q. (MS. TUREK) The Community Mental Health has provided you 18 a directive that you not write prescriptions? 19 A. That's actually a very frequent request. For instance, 20 when I've consulted at other institutions, it is for 21 consulting purposes only. Even at Munson Medical Center, 22 when I consult on a consultation liaison service, I 23 typically check with the requesting physician for his okay 24 to write for him my recommendations. It is ultimately the 25 responsibility of the requesting physician as I am only a 52 1 consultant to say yes or no regarding the medication 2 recommendations. 1:31P 3 Q. I gotcha. Is that so you don't step on their toes? 4 A. Yes, ma'am. 5 Q. That's so they call you back again? 6 A. Yes, ma'am. 7 Q. All right. Community Mental Health telling you not to 8 write the prescription, to your knowledge what is the 9 rationale for that? Same rationale that you just gave me? 10 MS. DEBLER: Same foundation. 11 THE WITNESS: That's almost the standard of 12 care. As a consultant you really are not the attending 13 and consequently the attending holds ultimate authority 14 for any medications prescribed to a patient and it's 15 common courtesy to render your considered opinion and for 16 the ultimate decision to lie with the attending physician. 1:32P 17 Q. (MS. TUREK) How frustrating is that sometimes? 18 A. Sometimes it can be very frustrating. 19 Q. So in Christopher Morden's care, you weren't the primarily 20 responsible physician, right? 21 A. No, ma'am, I was not. 22 Q. To your knowledge Dr. Wilcox was the one primarily 23 responsible for the medical care and treatment rendered to 24 Christopher Morden, right? 25 MS. LYNN: I'm going to object to form and 53 1 foundation. 2 THE WITNESS: To my knowledge Dr. Wilcox was and 3 is the jail physician and, therefore, would be the 4 physician prescribing the medications. 5 Q. (MS. TUREK) And he, therefore, would be the physician 6 primarily responsible for Christopher Morden's medical 7 care and treatment, right? 1:33P 8 MS. LYNN: Objection to form and foundation. 9 THE WITNESS: That commonly -- 10 MR. GANO: I think you have answered the 11 question. 12 Q. (MS. TUREK) No, no. 13 A. It sounds like the same question. 14 Q. I didn't get an answer to that part of it. 15 MR. GANO: I'm sorry. I thought you had asked 16 and she had given you an answer that Dr. Wilcox was and is 17 the jail physician. 18 MS. TUREK: Right. 19 Q. (MS. TUREK) So Dr. Wilcox was primarily responsible for 20 the care and treatment rendered to Christopher Morden, 21 right? 22 MS. LYNN: Same objection. 23 THE WITNESS: I actually don't know the lines of 24 authority. I'm presuming given that he is the jail 25 physician that he is the person responsible, but I do not 54 1 the know that for a fact. 2 Q. (MS. TUREK) Were there any other physicians that you 3 encountered during your care and treatment of Christopher 4 Morden? 5 A. I know that Dr. Wilcox often has a colleague cover the 6 jail for him and I don't know the time sequence of that so 7 that is why I'm hedging on my answer to you. 8 Q. You agree that the jail physicians are primarily 9 responsible for the care and treatment of the inmates, 10 right? 1:34P 11 A. Typically, the jail physician is the primary prescriber 12 and responsible for the care of the inmates, yes. 13 Q. And just so I'm clear on all points, you were not 14 primarily responsible for the care and treatment rendered 15 to Christopher Morden, right? 16 A. That's correct. 17 Q. Okay. I know I asked this. Maybe I didn't. You were 18 paid per visit or per patient? 19 A. I am paid for a two-hour time period. 20 Q. Regardless of whether you work like a dog or sit there 21 drinking coffee, right? 22 A. That's correct. 23 Q. Okay. So if you determine follow-up was necessary on a 24 patient that you had evaluated and made recommendations, 25 how did you make that follow-up arrangement? 55 1:35P 1 A. That goes typically -- although I can't say a hundred 2 percent of the time -- typically, what I do is I write 3 down what my recommendations are as well as a time 4 sequence for follow-up. That is my recommendation. If 5 it's taken, great, the patient is put on my list. If it's 6 not taken, then there is another patient substituted on my 7 list. 8 Q. So if a recommendation is not taken, the only way you have 9 of knowing that is that the patient didn't show up on your 10 list? 11 A. Provided I remember that he was supposed to be seen that 12 day. 13 Q. Back in February, March, and April of 2002, do you recall 14 if any of your recommendations with regard to any patient 15 were not followed? 16 A. I have no memory of that. 17 Q. Were any of the recommendations with regard to Christopher 18 Morden not followed? 1:36P 19 A. I have no knowledge of that. 20 Q. Just so I have it stated then, do you find out from the 21 Community Mental Health folks that you needed to see a 22 psychiatry patient? 23 A. Uh-huh. 24 Q. You would see the patient, evaluate the patient, and make 25 recommendations that may or may not include psychotropic 56 1 medication, right? 2 A. That's correct. 3 Q. And the prescription for the psychotropic medication would 4 actually be written or called in by the jail physician, 5 right? 6 A. I have no knowledge of how that actually transpires. 7 Q. So you wouldn't know until you saw this patient the next 8 week whether or not the psychotropics were even started, 9 right? 10 MR. GANO: You're not talking about this 11 patient. You're talking about a hypothetical patient? 12 MS. TUREK: Generally speaking, right. 13 MR. GANO: Any inmate? 14 THE WITNESS: I have no idea whether it's 15 followed or not until I do a follow-up on that patient and 16 then I would look and see what in fact he was on. 1:37P 17 Q. (MS. TUREK) Okay. And you might not have the opportunity 18 to do a follow-up depending on whether or not a 19 recommendation of yours is followed, right? 20 A. That is correct. 21 Q. If you made a recommendation that you needed to follow-up 22 up with this patient, any patient -- 23 A. Okay. 24 Q. -- and the patient did not show up on a list and the list 25 I mean is that next week's list -- 57 1 A. Uh-huh. 2 Q. -- have you ever actively said I think I need to see this 3 patient, you know, driven the point home with regard to 4 your recommendation? 5 A. I rely on the Community Mental Health workers to monitor 6 that for me. As I have noted, I have several positions 7 and consequently only limited memory span and have to rely 8 on ancillary personnel to keep my schedule straight. 1:38P 9 Q. Right. Has a Community Mental Health worker ever related 10 to you that your recommendation was not being followed 11 with regard to any inmate at the Grand Traverse County 12 Jail? 13 A. I don't recall ever having had that conversation with 14 anyone. 15 Q. That's a bad spot? 16 A. Not to say it's not occurred, I can't pull one out for 17 you? 18 Q. Sure. With regard to Christopher Morden, were your 19 recommendations followed? 20 A. When I saw him in follow-up, I believe approximately a 21 month after that, it appeared as though he was put on the 22 medications that I recommended. 1:39P 23 Q. Was he put on the medications that you recommended in the 24 dosing schedule that you recommended? 25 A. I would have to refer to the medical record to confirm 58 1 that. 2 Q. Would you like to do that? 3 A. Sure. 4 Q. We have an original record somewhere here if you need to 5 look at that. That's it. Take your time. Is now a good 6 time for a break for anybody? 1:40P 7 MR. GANO: Okay. 8 (Break was taken.) 1:50P 9 Q. (MS. TUREK) Were your recommendations followed after or 10 can you tell if your recommendations were followed 11 following your review of the original medical records? 12 A. It appears that my recommendations were followed for 13 2-12-02. 14 Q. Were your recommendations followed every time you made a 15 recommendation for the care and treatment of Christopher 16 Morden? 1:52P 17 A. Recommendations given on 3-12-02 were also followed. The 18 recommendations on 3-23-02 were begun. 19 Q. Were you -- strike that. The only times you saw 20 Christopher Morden then was on 2-12-02, 3-12-02 and 21 3-23-02? 22 A. Yes, ma'am. 23 Q. And when you say -- you didn't see him any other time? 24 A. No, ma'am. 25 Q. And when you say the recommendations from 3-23-02 were 59 1 begun, what do you mean? 2 A. I wrote for a cross taper of two medications of Seroquel 3 and Risperdal and they were begun, but it does not appear 4 to have been completely followed. 1:53P 5 Q. What do you mean by that? 6 A. I wrote for a cross taper for two days, then two days, 7 then four days, and that was on 3-23. The meds were, 8 according to this chart, started on 3-25 and he appeared 9 to have -- well, it's unclear to me whether these meds 10 were actually given or not because it looks like they were 11 all signed for, but I know he was deceased on 4-2 so my 12 reading of the record may not be accurate. This is not a 13 form that I am used to reviewing. 1:54P 14 Q. You don't usually see the medication administration 15 record, right? 16 A. Occasionally I am given a Xerox copy of medication records 17 to date. I have not reviewed this form in this format 18 before. 19 Q. So you have never seen that document before today, that 20 medication administration record before today? 21 A. Not the total form. 1:55P 22 Q. What do you mean by that? 23 MR. WIERDA: A brief objection. Did you call it 24 a medication administration record? 25 MS. TUREK: Oh, what is it called? 60 1 MR. WIERDA: Well, I just see it's titled 2 medication record 3 MS. TUREK: Oh, forgive me. 4 MR. WIERDA: Just for the sake of the record. 5 MS. TUREK: The medication record. I beg your 6 pardon. 7 Q. (MS. TUREK) Have you ever seen Christopher Morden's 8 medication record before today? 9 A. I cannot definitively say yes or no as quite frequently -- 10 I'm unsure when this practice started -- I would be given 11 a Xerox copy of a medication record indicating what 12 medications people were on so as to assist me in making 13 recommendations. That means that there are several drug 14 interactions that a psychiatrist should be aware of. The 15 best way to glean information would be from the actual 16 record of medications being administered as opposed to a 17 report from someone other than a health care provider. 18 Often patients get medication names incorrect, dosages 19 incorrect, which could very well complicate their care. 20 I'm uncertain when we put into place the delivery of the 21 medication record to me at the time of reviewing their 22 medications. 1:56P 23 Q. You said that sometimes you're provided with a Xerox copy. 24 Would that be the Xerox copy of the medication record as 25 of the date that you're seeing the patient? 61 1 A. Yes. 2 Q. I see. So when you treated Christopher Morden, were you 3 provided with a Xerox copy of his medication record? 1:57P 4 A. Up to the date that I was seeing him that potentially is 5 true, but I can't comment whether that's true or not true. 6 But potentially it could be true. I quit frankly don't 7 recall. 8 Q. Okay. 9 A. And quite frankly it often is disregarded after I reviewed 10 it so there would be no actual record of it. 11 Q. So there was some practice back when Christopher Morden 12 was in the Grand Traverse County Jail in which you would 13 come in and assess a patient and be provided with a copy 14 of the medication record, right? 15 A. I'm unclear whether it started at that time or sometime 16 thereafter. 17 Q. Okay. What other medical records, generally speaking, 18 would you be provided with in your care and treatment of 19 an inmate? 1:58P 20 A. Approximately three-quarters of the time, I'm not provided 21 with any back medical records other than perhaps a list of 22 medications that the patient is currently on. In Mr. 23 Morden's case, I believe we identified previous care 24 givers. I'm uncertain as to the timing of the request for 25 those medical records, but I do remember having reviewed 62 1 them at some point in the course of his treatment. 2 Q. Is that a request that you made to receive prior records 3 of his care and treatment? 4 A. It is standard practice that when a previous provider has 5 been identified that a release of information is filled 6 out so as to allow the jail to get a copy of those 7 records. In Chris' case, he was seen by Antrim Kalkaska 8 Community Mental Health and I believe an additional 9 psychiatrist. 1:59P 10 Q. Dr. McDermid? 11 A. Yes. And I believe releases were filled out so that we 12 could have a copy of those. 13 Q. And those releases, that would be something that Community 14 Mental Health would want, right? 15 A. I imagine that all care providers would like a copy of 16 that have so as to give good care. 17 Q. Wouldn't it be more correct to say that you would imagine 18 that all care providers should want a copy of the prior 19 medical records? 20 A. I believe that's a matter of opinion. 21 Q. Okay. Did you request copies of Christopher's prior 22 medical records in order to care and treat him? 2:00P 23 A. It's my standard practice that whenever an additional 24 provider has been identified we request a release of 25 information to be filled out with the hope that that 63 1 provider would send us those medical records. 2 Q. You said that three-quarters of your time you're not 3 provided with any documentation to use during your 4 assessment. Are you provided with a record of vital signs 5 prior to your care and treatment of the Grand Traverse 6 County inmate? 4:56P 7 A. As a matter of course, I usually only see patients who are 8 medically stable. I would, therefore, assume that their 9 vital signs would be stable as well. Do I get a written 10 document indicating current vital signs? No. 11 Q. Is it your custom and habit to obtain vital signs on 12 patients that you have treated at Grand Traverse County 13 Jail. 14 A. It's my expectation that I would be informed if there were 15 any abnormalities. It's a common practice called charting 16 by exception. If you're not notified, then you're safe to 17 assume that everything is within normal limits. 2:02P 18 Q. Are you saying the standard of care does not require us as 19 a psychiatrist to inquire into whether or not the vital 20 signs are normal on a patient who's being provided with 21 psychotropic medications? 22 A. If a psychiatrist is in private practice, then it behooves 23 the psychiatrist to be aware of the vital signs. If a 24 psychiatrist is working with a group of people, he or she 25 has to rely on ancillary personnel to chart by exception. 64 1 Q. I'll back up a couple answers ago. Are you suggesting 2 that the standard of care for a psychiatrist in caring for 3 an inmate is under the assumption that the inmate is 4 medically cleared? 2:03P 5 MR. GANO: Are you asking in reference to -- 6 MS. TUREK: Generally speaking. 7 MR. GANO: -- the broad spectrum or the specific 8 relationship that she's describes as a consulting only 9 physician in a jail setting? 10 MS. TUREK: My assumption is that's what 11 we've -- 12 MR. GANO: I mean I just want to make sure that 13 you're limiting the scope of your questions. 14 MS. TUREK: Right, not about your private 15 practice. 16 MR. GANO: Not a private practice. 17 MS. TUREK: Right. 18 MR. GANO: Not a primary provider. 19 MS. TUREK: Right. 20 MR. GANO: But in the scope she has described 21 her relationship in providing services to inmates in the 22 Grand Traverse County Jail. 23 MS. TUREK: Good. I gotcha. All right. Let me 24 try. 25 MR. WIERDA: I was going to put an objection 65 1 here. I don't think you've given us enough details for a 2 hypothetical perhaps. 3 MS. TUREK: Sure. 4 THE WITNESS: Would you mind repeating the 5 question? 2:05P 6 MS. TUREK: This is mental gymnastics, that's 7 for sure. No, they've brought up valid points. 8 Q. (MS. TUREK) You're not the primary care provider -- 9 A. Correct. 10 Q. -- in a jail setting, right? 11 A. Correct. 12 Q. And with regard to a jail setting, the assumption of the 13 psychiatrist is within the standard of care to assume that 14 the patient is medically clear? 15 A. Yes, ma'am. 16 Q. And the assumption that the patient is medically cleared 17 would be reasonable if there is a jail doctor on staff? 18 A. Yes, ma'am. 19 Q. And the assumption that the patient is medically clear 20 would also take into account that there are nurses caring 21 for this same inmate, correct? 22 A. Yes. 23 Q. I guess I would ask then who's minding the store with 24 regard to the side effects of a psychotropic group of 25 medications on an inmate? 66 2:06P 1 MS. LYNN: I'll object to the form of the 2 question. 3 MR. GANO: Join. 4 MR. WIERDA: I'll join. 5 MS. LYNN: That means nobody liked the question. 6 MR. GANO: I think it was the minding the store 7 business. 8 THE WITNESS: Given my limited involvement with 9 an inmate's care, I am not in a position where I can 10 accept the responsibility for monitoring ongoingly 11 potential side effects of a particular medication. 2:07P 12 Q. (MS. TUREK) How then do you make the risk benefit 13 analysis in providing antipsychotic medications with 14 regard to side effects? 15 A. Side effects is a rather cumbersome topic. Any patient at 16 any point in time can have any side effect from any 17 medication. However, there are some side effects that are 18 more prominent with some medications than with other 19 medications. What I just said with you is pretty much 20 what I say to every patient who starts on medications and 21 then I follow it with if something unusual is happening, 22 you need to tell the staff about it and we'll take a look 23 and adjust accordingly. 24 I typically hit the high points, if you will, 25 the most common side effects for Risperdal. There are 67 1 particular medication side effects that are common for 2 Seroquel. There are particular medication side effects 3 that are common. The only other drug at that point in 4 time that was available to us was Zyprexa of which I 5 believe those side effects would put that as a third 6 choice on my list of medications. 7 This in a conversation also with Mr. Morden, as 8 I do with all my patients, I ask them do you have any 9 other questions and keep asking do you have any other 10 questions until they say no. This is my standard practice 11 with all patients. So that we are in agreement as to the 12 course of action. If you don't have agreement with the 13 patient, then it's unlikely the patient will take your 14 medication and have the desired result so it's important 15 to build a therapeutic alliance. 2:09P 16 Q. What if the patient is so whacko they don't understand 17 what you're saying? 18 MR. WIERDA: Objection to form. 19 MR. GANO: Objection. 20 MS. LYNN: Join. 21 Q. (MS. TUREK) What if the patient is so -- 22 A. Compromised. 23 Q. -- compromised -- thank you -- that they do not understand 24 what you're saying? 2:10P 25 A. Then I wouldn't be evaluating this patient. This patient 68 1 would be in the emergency room getting medical clearance 2 and probably be admitted to the inpatient psychiatric unit 3 for more definitive care. 4 Q. Would you agree Christopher Morden needed more definitive 5 care than he was being provided in the jail? 6 MR. GANO: At what point in time? I'll object 7 to the form of the question as it's stated. 8 Q. (MS. TUREK) At any point in time. 9 MR. WIERDA: And as to which providers. I will 10 object, also. 11 THE WITNESS: When seen for his initial 12 psychiatric evaluation, the determination was made that he 13 could be adequately cared for in the Grand Traverse jail 14 with appropriate medication adjustment. A provisional 15 diagnosis of schizophrenia paranoid type was made which 16 was in concordance with a previous diagnosis made by 17 Antrim Kalkaska CMH. 18 At the time that I saw him, he was suffering 19 from some hallucinations, but they were not so distressing 20 that I thought he needed immediate inpatient acute care. 21 I say that when I look to see that I was going to 22 follow-up in one month, that tells me that I was fairly 23 certain that he was safe enough and stable enough to be 24 maintained in a controlled setting as an outpatient. 2:11P 25 Q. (MS. TUREK) And when you say controlled setting, what do 69 1 you mean? 2 A. Such as provided by the Grand Traverse County Jail. He's 3 supervised. He gets his medications. If he doesn't take 4 his medications, it's noted. And we have a sense about 5 what a symptom profile would look like. We have a sense 6 about symptoms versus taking his meds. We can look for 7 adverse drug reactions which would be appropriately 8 monitored by the medical staff and/or correctional staff 9 who interact with him regularly. He also can self report 10 and put out a kite as you indicated before which is a 11 request for assistance. 2:12P 12 Q. You said that when you initially saw him, you thought it 13 would be okay or adequate care could be provided with 14 appropriate medicine adjustment. Did you adjust his 15 medicine the first time you saw him? 2:13P 16 A. I made a recommendation to increase his Risperdal so as to 17 cover his auditory hallucinations. 18 Q. You testified earlier that recommendation was followed to 19 your knowledge? 20 A. To my knowledge, it was followed. 21 Q. You said that the physician, the jail physician can look 22 for adverse medicine reaction? 23 A. The jail physician can do it, the correctional officers 24 can do it, the nursing staff can do it, fellow inmates can 25 do it, and the patient can self report. 70 1 Q. If the fellow inmates don't say anything, if the jail 2 officers don't know enough -- and this is a 3 hypothetical -- and the nursing staff doesn't encounter 4 the patient and the patient does not self report, who's 5 responsible for watching for medication reactions? 2:14P 6 MR. GANO: Objection. 7 MS. LYNN: I object to form and foundation. 8 MR. WIERDA: Also requires a legal conclusion. 9 MS. LYNN: Or speculation. 10 MR. GANO: I'll join. 11 Q. (MS. TUREK) To your knowledge. 12 A. I am unfamiliar with the reporting structure at the jail 13 so as not to be able to give you an informed answer. 14 Q. I appreciate that you were not an employee of the jail. I 15 understand that. But if you make a recommendation for a 16 psychotropic medication in Christopher Morden's case -- at 17 one point in time, he was on three different psychotropic 18 medications, right? 19 A. Correct. 20 Q. If you make those recommendations, you would agree that 21 the standard of care is to assume that someone is 22 monitoring this new human being for medication reactions, 23 right? 2:15P 24 A. That is my assumption, yes. 25 Q. And your assumption is that who is monitoring the inmate 71 1 for medication reactions? 2 A. I would assume that the correctional officers, the nursing 3 staff, the medical doctor are all watching for medication 4 side effects as well as Mr. Morden to have the presence of 5 mind of saying something is wrong. 6 Q. Sometimes the medications take away the ability to have 7 the presence of mind to say something is wrong, right? 8 A. That's correct, as well as the illness that we are 9 treating. 10 Q. In Christopher Morden's case, maybe you're not aware that 11 sometimes he was unresponsive, right? 2:16P 12 MS. LYNN: I object to form. 13 MR. GANO: When are we talking? Sometimes he 14 was unresponsive? Do you mean while an inmate? 15 MS. TUREK: Yes. 16 MR. GANO: Specific times. 17 MS. TUREK: This is while he's an inmate. Come 18 on now. 19 MR. GANO: Well, no -- excuse me. 20 MS. TUREK: Sorry. Go ahead. 21 MR. GANO: This is histrionics. 22 MS. TUREK: It is. I'm there. 23 MR. GANO: You're there. I agree. 24 MS. TUREK: Go ahead. 25 MR. GANO: Can we identify a point in time? Are 72 1 we talking after her consult, before her consult, in 2 between her consults? Just give us a time frame. 3 MS. TUREK: Sure. 4 MS. LYNN: And I have an objection to form and 5 foundation. 6 MS. TUREK: Sure. 7 Q. (MS. TUREK) There were points in time after your first 8 consultation and while Christopher was still alive that 9 Christopher was nonresponsive, correct? 10 A. In my memory I recall having read prior to a revisit a 11 report from correctional officers indicating that he was 12 rocking in his bunk and did not respond to some commands. 13 Shortly thereafter more correctional officers were called 14 per the report. The patient then did in fact respond and 15 move to another cell. I believe it was noted in the CMH 16 documentation that he was surprised that the cell that he 17 was in -- I can't recall if whether or not he was pleased 18 or displeased with this particular cell. When I see that, 19 two things come to mind. One: He was responding to 20 internal stimulation in which case the medications need to 21 be adjusted up. Or two: He's self stimulating; i.e., 22 incredibly bored. Or sometimes it's been known in the 23 jail population to be -- how do I say this -- manipulating 24 observations for a later forensic evaluation. 25 Q. For a what evaluation? 73 1 A. For a later forensic evaluation. 2 Q. In your experience, why would someone fake it? 3 A. Or manipulate the circumstances. 4 Q. Or manipulate the circumstances. Why would a patient do 5 that? 6 MR. GANO: Inmate. 7 Q. (MS. TUREK) Why would an inmate do that? 8 MR. GANO: I object to the question. 9 THE WITNESS: Often the motivation is to get a 10 not guilty by reason of insanity. Paranoid schizophrenia 11 is such a diagnosis as that may be a viable defense. 9:05P 12 Q. (MS. TUREK) Was Christopher sick? 13 A. Christopher had a mental illness. 14 Q. Would you grade the mental illness in severity or could 15 you grade it in severity? 16 A. There are four types of schizophrenia. He had, as best I 17 could tell, a provisional diagnosis of paranoid 18 schizophrenia. It starts at a fairly early age in one's 19 teenage years. It has a consistent downhill course with 20 plateaus of good functioning and then drop-offs to less 21 functioning ability which usually necessitates a 22 hospitalization and then stabilization. Unfortunately, we 23 find a lot of paranoid schizophrenics in our street people 24 in our southern cities or alternatively housed in the 25 correctional facilities of this country. 74 2:20P 1 Q. That's because the government has chosen not to spend 2 money on helping them, right? The record will reflect 3 that the deponent held up her ice tea bottle as a salute. 4 MS. LYNN: We're going to Washington D.C. when 5 we leave here. 6 MS. TUREK: Off the record. 7 (Off-the-record discussion.) 8 Q. (MS. TUREK) When I asked you to grade his mental illness, 9 paranoid schizophrenia was a provisional diagnosis, right? 2:21P 10 A. Yes, ma'am. 11 Q. That provisional diagnosis had been made prior to your 12 arrival in Christopher Morden's life, right? 13 A. A review of the medical records I believe indicates that 14 was also the diagnosis that he had received at Antrim 15 Kalkaska CMH as well as from Dr. McDermid. 16 Q. What does the word provisional mean with regard to a 17 provisional diagnosis? 18 A. It's usually the working diagnosis which we use to treat 19 the patient. 20 Q. Is there ever a final diagnosis like, let's say, 21 myocardial infarction we know is not provisional but 22 proved concrete with regard to mental illness? 23 A. The tincture of time is usually how we make a lot of these 24 diagnoses. Given that we just take a snapshot, we could 25 use a more general rubric such as psychotic disorder not 75 1 otherwise specified. With time we get more and more 2 specific until such point we can say with a certain amount 3 of medical certainty that this is in fact what this 4 patient or inmate might have. 2:22P 5 Q. Were you ever able to including now arrive at a reasonable 6 degree of medical certainty with regard to Christopher's 7 diagnosis? 8 A. I only saw him for just a few months. Consequently, it 9 still behooves me to say it's provisional although there's 10 much documentation where that would be the likely outcome. 11 Should he continue in my care, I probably would give him 12 that rubric. 13 Q. Would you have given him any other diagnoses had he 14 continued in your care based on the care that you had 15 provided? 16 A. At the time that he was assessed on 2-12-02, I was ruling 17 out an anxiety disorder, again, not otherwise specified. 18 It was unclear to me whether this was a symptom of his 19 paranoid schizophrenia or whether in fact he had a true 20 anxiety disorder whether that be a general anxiety 21 disorder or other subsequent anxiety disorder such as 22 post-traumatic stress disorder or any number of things 23 listed in that category. 2:24P 24 Q. Any other diagnoses that you may have made? 25 A. Probably substance dependence. His history was replete 76 1 with numerous interactions with both drugs and alcohol. I 2 believe he got the diagnosis of dependence as opposed to 3 abuse given his difficulty with withdrawal. 2:25P 4 Q. And that's the defining characteristic? 5 A. Between abuse and dependence, yes, ma'am. 6 Q. Any other diagnoses that you may have made? 7 A. I believe that's at the time the only diagnoses that I 8 entertained or had documentation to believe were in 9 existence. 10 Q. Okay. Were you aware that he was abused as an infant, 11 that Christopher was abused as an infant? 12 A. I was aware of this. Unfortunately, we could not go into 13 it in any great detail. It was sufficient enough for me 14 to entertain an anxiety disorder not otherwise specified 15 with thoughts that it would be further elucidated with 16 treatment. 2:26P 17 Q. If you had carried on with his further care and treatment, 18 right? 19 A. Uh-huh. 20 Q. What is your opinion with regard to Chris' mental illness 21 and the fact that he was pretty badly physically abused 22 prior to the time the Mordens encountered him which was 23 from birth to seven months old? 24 A. I did not go into great detail regarding that given the 25 limited time I have to evaluate these patients. It was 77 1 clear that was a fruitful area for us to discuss at some 2 later date. That's actually why I kept it on the radar 3 screen. I thought that would provide assistance in 4 developing our therapeutic alliance. As is common with 5 schizophrenia, there's difficulty with trust issues as is 6 common with PSD. There is difficulties with trust issues. 7 One must not enter the china shop with a bulldozer but 8 instead tiptoe lightly amongst the tulips 9 I anticipated having an ongoing relationship 10 with Mr. Morden if this was to be provided within the 11 structure of CMH and the time limitations. I actually 12 found him to be a very pleasant young man and certainly 13 someone who was in need of assistance. I believe I felt 14 somewhat motherly towards him. 15 This is probably not the time to say this, but I 16 was quite shocked when I heard of his passing and 17 certainly saddened, a young man kind of potentially who 18 had seemingly turned the corner with regard to his 19 involvement with the authorities. It was hopeful that he 20 had a new chance and with appropriate help and therapy and 21 structure, I thought he could have done quite well. He 22 was actually a pleasure to work with. 2:29P 23 Q. That's good to hear that, Doctor. Was his abuse as an 24 infant the biggest contributing factor to his mental 25 illness? 78 1 A. No. I believe they are separate. I believe the PSD is 2 usually environmental and that schizophrenia as time 3 passes we find out this theory is probably most true 4 genetic. And that environmental factors play a role in 5 the development of these illnesses also, but the 6 predisposition is there when the egg meets the sperm. 7 Q. And the environmental factor in this kid's case would be 8 the abuse as an infant? 2:30P 9 A. I believe that contributed to the severity of his mental 10 illness, yes. 11 Q. How important was it in Christopher's life that he was 12 abused at such a young age? 13 A. Our very first years are the very most important to us. 14 It's our formative years. It's where we build our ego 15 structure. It's where we build trust in relationships. 16 It's where we develop our personalities and our 17 temperaments. We are born with a temperament, but our 18 personality sort of develops from that. They are either 19 supported or denigrated and so in the first seven years of 20 life just having experienced 18 month old twins and 21 watching them grow through that I have watched them become 22 who they are. I have a renewed appreciation how important 23 those first couple years of life are. 24 Q. How about the first seven months of life? 2:31P 25 A. Infants have an amazing cognitive ability even at that 79 1 young age. They probably won't remember details, but they 2 remember feelings. They get a sense of trust. Seven 3 months you start your building blocks. And if you're 4 fortunate enough to be rescued by a supportive family, you 5 can perhaps overcome the initial devastation of a poor 6 beginning. 7 Q. Do you think Christopher had overcome the initial 8 devastation of that poor beginning? 9 A. I think he was a young man in a great deal of conflict, 10 internal conflict. 11 MS. LYNN: I didn't hear that answer. A great 12 deal of... 2:32P 13 THE WITNESS: A great deal of internal conflict. 14 MS. LYNN: Thank you. 15 THE WITNESS: He unfortunately had the 16 additional burden of a genetic disorder which makes it 17 very difficult. 18 Q. (MS. TUREK) And so if the parents experience that 19 parental guilt that comes with our DNA, your advice to 20 them would be that this was something that was not 21 preventable, this paranoid schizophrenia? 22 A. No, ma'am, it's not preventable. 23 Q. And it's not something that can be cured by hugs and 24 kisses, right? 25 A. The damage from abuse can be ameliorated with hugs and 80 1 kisses, but the actual chemical imbalances inherent in 2 schizophrenia cannot. They have to be addressed with 3 medication so as to allow the brain to work in a fully 4 functioning fashion. 2:33P 5 Q. To your knowledge and your review of the medical records 6 that were generated prior to the Grand Traverse County 7 Jail stay, Christopher was taking steps to get better, 8 right? 9 A. Yes, ma'am, he was. 10 Q. He was committed to getting better, right? 11 A. Yes. 12 Q. Let's switch gears a little bit here. Have you ever been 13 a party in any other lawsuit? 14 A. No, ma'am. You're my first. 15 Q. I have a real hard time keeping my mouth shut so you can't 16 do that. Do you function as an expert in medical/legal 17 setting? 18 A. Yes, ma'am. 19 Q. In which capacity? 20 A. I testify quite frequently in front of the Grand Traverse 21 Probate Court as well as have testified on some forensic 22 cases down in Ypsilanti at the Forensic Center. 2:34P 23 Q. Do you believe that Christopher -- would you have 24 supported a defense of insanity in Christopher's case? 25 A. I was not evaluating Mr. Morden for the purposes of a 81 1 forensic evaluation. My job was basically to provide 2 medication and consultation for a young man who had 3 previously been medicated. It's my understanding that Dr. 4 Wilcox often refers out if psychiatric medications are 5 present when the patient is admitted to the Grand Traverse 6 jail. Had this been a forensic evaluation completely 7 different questions would have been asked. I don't want 8 to know the answers to those questions. 2:35P 9 Q. Okay. 10 A. And so can I testify that he had mental illness, yes, but 11 that also requires knowing motivation, knowing mental 12 status at the time of the commitment of the crime, knowing 13 whether or not medications can put the patient in a 14 position to be able to assist in his own defense, none of 15 those questions were addressed with this patient. 16 Q. So you're not in a position right now to know whether or 17 not Christopher was insane at the time he committed the 18 offense? 19 A. Correct. 20 Q. So you're not in a position to say whether or not a claim 21 of insanity would even have been supported by you, right? 22 A. That's correct. 23 Q. With regard to med-mal practice litigation, do you 24 function as a medical/legal expert? 2:36P 25 A. I have been asked to review some charts in my time as a 82 1 physician. 2 Q. Have you ever been asked by any person in this room to 3 review charts for a medical malpractice litigation? 4 A. No, ma'am. 5 Q. What's the difference between a psychosis and 6 schizophrenia? 7 A. Psychosis is a very general term. It's used to 8 encapsulate a thought process or a lack therefore. It 9 captures hallucinations, delusions, bizarre behaviors. 10 Schizophrenia is a more circumscribed symptomatology that 11 has psychosis associated with it but also other symptoms 12 such as affect flattening, lack of volition. If one is 13 uncertain as to the labeling of a patient, one might go 14 and call him psychotic disorder not otherwise specified 15 and then with time refine one's diagnosis and in this case 16 refine it as far down as a provisional diagnosis of 17 paranoid schizophrenia. 2:37P 18 Q. So then psychosis would be the flattened -- 19 A. More general terms. 20 Q. And paranoid schizophrenia would be a subset of psychosis? 21 A. Yes. 22 Q. How do you test for whether or not it's psychosis versus 23 something further down the list like paranoid 24 schizophrenia? 2:38P 25 A. How do you test for it? 83 1 Q. Yeah. How do you arrive at -- you know, what does the 2 standard of care require for a psychiatrist to arrive at 3 either a diagnosis or a provisional diagnosis of paranoid 4 schizophrenia? 5 A. To diagnose schizophrenia the criteria require that 6 symptoms be present for more than six months. Prior to 7 six months, it would have a diagnosis of schizophreniform 8 or alternative acute psychotic episode. Once it's been 9 present for six months or longer, there is a provisional 10 diagnosis made. The symptoms of schizophrenia -- okay. I 11 just answered your questions as asked. 12 Q. Sure. That's right. Christopher had symptoms of 13 schizophrenia, right? 14 A. Right. 15 Q. And it's paranoid schizophrenia because of the 16 hallucinations, right? 2:39P 17 A. And delusions, yes. 18 Q. And delusions. What does the standard of care require for 19 a psychiatrist as to which medication will be prescribed? 20 A. The current standard of care and that in place two years 21 ago included atypical antipsychotic medications as opposed 22 to typical antipsychotic medication as the atypicals had a 23 less incidence of side effects as well as the dreaded 24 Tardive Dyskinesia. 25 Q. What's the difference between atypical and typical? Maybe 84 1 you can define atypical versus typical antipsychotic? 2 A. Sometimes they are called conventional. Sometimes they 3 are called new versus old. We have had the old 4 medications such as Prolixin, Haldol, Navane, Moban. 2:40P 5 Q. So how about this -- I'm sorry. Go ahead. 6 A. There's one, Chlorpromazine, which is the one I'm thinking 7 of which psychotic medications are measured against by way 8 of potency. 9 Q. Is that Thorazine? 10 A. Uh-huh. 11 Q. Do you still use that? 12 A. Sometimes. 13 Q. Wow. 14 A. Those are the old meds. Those are called the typical 15 meds. Their side effect profiles are pretty huge because 16 they hit a number of different receptors. With time 17 science has been able to clean them up so that they hit 18 particular receptors in particular amounts, targeting 19 receptors, if you will, and subsets of receptors; 20 therefore, targeting specific symptoms known to be 21 associated with a disease entity. Those medications in 22 2002 consisted of Risperdal, Seroquel, Zyprexa and 23 Clozaril. 2:41P 24 Q. Those are what are considered atypical? 25 A. Atypicals. 85 1 Q. Risperdal, Celexa, Seroquel. 2 A. Seroquel. 3 Q. I beg your pardon. What was Celexa considered? Typical? 4 A. Celexa is not an antipsychotic. It is an antidepressant. 5 Q. Thank you. I want you to know that I have that written 52 6 times here. Okay. So how do you determine which drugs 7 will be provided to the patient? In this case he came on 8 board to you with a couple of medications. 9 A. Yes. 10 Q. Does the standard of care require you to evaluate whether 11 or not those medications were appropriate? 2:43P 12 A. Yes, ma'am. 13 Q. And did you determine whether or not those medications 14 were appropriate for Christopher? 15 A. Given the standard of care in 2002, those were the most 16 appropriate medications for him. 17 Q. Okay. Let's talk about the medications. We know 18 Risperdal is for schizophrenia, right? Do you have to 19 make a call? 20 A. No. I was just checking the time. 21 Q. Remember that nonverbal thing. If you do, that's okay. 22 Risperdal is atypical? 23 A. Atypical. 24 Q. Atypical. 25 A. Nonconventional. 86 1 Q. Nonconventional. 2 A. Or new. 3 Q. Or what? 4 A. New. 2:44P 5 Q. New, yes. If a patient is dehydrated the clearance of 6 that drug can be decreased up to 60 percent, right? 7 A. That's true. 8 Q. Side effects include extrapyramidal symptoms, right? 9 A. That is most troublesome in overdoses of 4 milligrams. 10 Q. In doses under 4 milligrams -- and it's 4 milligrams per 11 day or 4 milligrams per dose? 12 A. Four milligrams per day. 13 Q. Per day. Was Christopher ever receiving more than 4 14 milligrams per day of Risperdal? 15 A. Yes, ma'am. 16 Q. So he was at an increased risk for neuro malignancy 17 syndrome? 18 A. No. He was at increased risk for extrapyramidal side 19 effects? 20 Q. And what are extrapyramidal side effects? 21 A. They are where the basal ganglion causes involuntary motor 22 movement. Oftentimes, EPS is an early sign of a potential 23 Tardive Dyskinesia but not always. They are easily 24 treated with a medication such as Cogentin, Artane. Often 25 it is displayed by what's called cogwheel rigidity. For 87 1 the layman to be able to pick it up, you could say if he 2 looks Parkinsonian, he probably has EPS. 2:45P 3 Q. And Parkinsonian is the tremors? 4 A. Can be tremors but mostly it's a shuffling gait, a 5 stiffness in his ability to ambulate, and this cogwheel 6 rigidity. 2:46P 7 Q. And the cogwheel rigidity is what again? 8 A. It's a release and catch as one moves a patient up and 9 down. You will actually put your hand on the muscle, feel 10 the release and catch again, very much like the cogs of a 11 clock. 12 Q. Extrapyramidal -- 13 A. Side effects. 14 Q. -- side effects. That's EPS? 15 A. Extrapyramidal symptoms, yes. 16 Q. Symptoms, okay. Does EPS progress? I mean if it was a 17 continuum, would it be EPS, then Tardive Dyskinesia, then 18 Neuro Malignant Syndrome? 19 A. No. Not related. 20 Q. Go ahead. What's the difference between the three? 21 A. Neuro Malignant Syndrome is a poisoning, if you will, of 22 the autonomic nervous system. 23 MS. LYNN: I didn't hear that word. 24 THE WITNESS: Poisoning of the autonomic nervous 25 system where you have autonomic instability. You have 88 1 elevations in temperature. You have heart rate changes, 2 sometimes up, sometimes down. You have blood pressure 3 changes. You have muscle rigidity which results in 4 breakdown of myoglobin and consequently an increase in 5 CPK, creatine phosphokinase. This is a phenomena 2:47P 6 that occurs over time. It can prove fatal if not 7 recognized and treated. Usually these patients who 8 develop this are taken to the emergency room, given 9 supportive care which requires usually IV hydration. 2:48P 10 If cessation of the offending agent is not 11 sufficient in turning the patient's condition around, 12 Dantrolene or Bromocriptine can be added to the treatment 13 regime and usually the patient in this day and age does 14 quite well. In older days when we didn't recognize it as 15 quickly, it was more insidious especially with the older 16 medications. There was about a 50 percent death rate. 17 I have treated a number of NMS patients in the 18 hospital. It's actually more prominent than most people 19 would think. I'm pretty good at picking it up when it's 20 there. 2:49P 21 Moving onto the next one which is Tardive 22 Dyskinesia, it can occur with or without any exposure to 23 psychotic medications, antipsychotic medications. It's 24 about 17 percent in the elderly population without any 25 exposure. It sometimes is a function of aging in the 89 1 striatum in the brain as well as the basal ganglion. You 2 will see it if in fact a patient has been exposed 3 typically to the medications I previously suggested such 4 always Haldol, Navane, Moban, Thorazine. It's a huge risk 5 factor for those medications, actually being some of the 6 motivation for having atypical neuroleptics which tend not 7 to have that as a common finding. 8 EPS, moving on, is a finding at certain levels 9 of Risperdal, less so with the newer antipsychotic 10 medications. Seroquel, you have to get up, pretty up in 11 your dosing to be able to see any EPS. It's not very well 12 documented in the literature that EPS occurs with 13 Seroquel. We're seeing with the newest medications just 14 out this past year or two some EPS with those drugs, but 15 that was the muscular involvement and Parkinsonian 16 symptoms were the reason for the development of the 17 atypical neuroleptic medications. 18 Do you have an understanding of all three now? 2:50P 19 Q. You betcha. I don't have the education you have. I guess 20 I'm having a hard time comprehending why all three of 21 those are not effects -- how do I say this? 22 A. A continuum. 23 Q. They are not all autonomic? 24 A. Actually, no, they are not all autonomic. 25 Q. Which one is not? 90 1 A. EPS is not autonomic. It's basal ganglion which is 2 musculature. It controls how we move our muscles. 3 Tardive Dyskinesia is also. The only one that's autonomic 4 would be the neuromuscular movement syndrome, a 5 Neuroleptic Maglignant Syndrome, also called a Malignant 6 Hyperthermia. 7 Q. With the assumption that hyperthermia must occur in order 8 for diagnosis of NMS to occur? 9 A. (Nodding head up and down.) 10 Q. Do you agree that hyperthermia must always be present in 11 order to make a diagnosis of NMS? 2:52P 12 A. Actually, I don't agree with it. It's one of the symptoms 13 that you should be looking for. I have in fact seen a 14 case where the patient was in fact just the opposite, was 15 hypothermic, but clearly had NMS. 16 Q. Did Christopher have EPS, Tardive Dyskinesia, or NMS to 17 your knowledge? 18 A. When I saw him on those three occasions, I believe I made 19 a note that on 3-12-02 I believe I had seen a report about 20 potentially him acting a little stiff and consequently 21 checked him and my note says no p.m. triangle/triangle 22 apostrophe S which is my shorthand sign for no psychomotor 23 changes; i.e., I didn't pick up any cogwheel rigidity on 24 him and, therefore, given that's a very strong sign that 25 there is any muscular involvement that he did not have 91 1 this. One does not tell the patients that you're doing 2 this because they will make an attempt at having that 3 symptom if they are in fact having a fictitious disorder. 2:54P 4 Q. If you had seen cogwheel, which of the three that we've 5 been discussing would have popped into your head? 6 A. Risperdal. 7 Q. Which of the three of the diseases? 8 A. Oh. EPS. 9 Q. But muscular rigidity is a finding in NMS, right? 10 A. It's one of the symptoms that may be present, but the 11 reason why the CPK elevates is that there's 12 rhabdomyolysis. There's muscle breakdown. 13 Q. The muscles that you attribute the muscular rigidity to is 14 the rhabdomyolysis in NMS cases? I guess I'm trying to 15 figure out how you jumped -- 16 A. The cogwheeling -- the cogwheeling is something that can 17 be, in fact, found across all three. 2:55P 18 Q. Okay. 19 A. It's just one of the many things that you're looking for 20 across all three. Really, the muscular involvement in NMS 21 is the rhabdomyolysis, the breakdown of muscles, and 22 that's due to the hyperthermia and sometimes you get 23 tremors and that causes rhabdomyolysis. Sometimes it's 24 high fevers causes muscle breakdown. 25 Q. The muscle rigidity in and of itself is not -- 92 1 A. No. Muscle rigidity in and of itself is not indicative of 2 NMS. There must be other things present. 3 Q. Great, but I'm suggesting here -- 4 A. Sorry. 5 Q. That's okay. -- that muscular rigidity in and of itself 6 would cause muscle breakdown, right? 7 A. To a certain extent, yes. 8 Q. In Christopher's case when you saw him on March 12th, he 9 had muscular rigidity, right? 2:56P 10 A. On March 12th, no, in checking with him he had no 11 psychomotor changes. 12 Q. But you noticed the rigidity, correct? 13 A. No. I got a report. 14 Q. The muscle rigidity isn't something that's constant until 15 an end stage of NMS, right? 16 A. Wrong. 17 Q. Isn't NMS a progressive -- 18 A. Yes. 19 Q. Right. So in the beginning of NMS, if you will, the 20 muscular rigidity could be intermittent, right? 21 A. Right. Uh-huh. 22 Q. Isn't it possible that at the time you examined 23 Christopher on March 12th the reason the muscular rigidity 24 was not present was because he was in the early stages of 25 NMS? 93 1 A. The likelihood of that is slim. I will never say never to 2 a patient. 2:57P 3 Q. In fact, NMS can vary from 45 minutes to 65 days, right? 4 A. The most common is about three weeks in developing, ten 5 days to twenty-one days in developing. Sixty-five days is 6 pretty far out there and forty-five minutes, there's 7 something else going on in addition. 8 Q. Three weeks is the time period from March 12th to the time 9 of Christopher's death, right, April 1st? 10 A. I would calculate more like two weeks, but... 11 Q. Two weeks is within three weeks, right? 12 A. Uh-huh. 13 Q. Is that a yes? 14 A. Yes, ma'am. Sorry about that. 15 Q. When you examined Christopher on March 12th, he did not 16 have EPS, right? 17 A. Correct. 18 Q. He did not have Tardive Dyskinesia, right? 19 A. Right. 20 Q. He could have had NMS, but he was not exhibiting symptoms 21 or findings as far as you were concerned, correct? 2:58P 22 A. Correct. There is nothing in his exam that indicated that 23 process was ongoing. 24 Q. You didn't have access to vital signs when you examined 25 Christopher any of the three times you examined him, 94 1 right? 2 A. That's correct. 3 Q. And, again, just so I'm clear, you only saw Christopher 4 three times? 5 A. That's right. 6 Q. Each time you made a recommendation to Dr. Wilcox, right? 7 A. I wrote a recommendation that typically arrives on Dr. 8 Wilcox's desk. I cannot confirm that. That is the 9 typical sequence of events. 10 Q. Does that mean you did not discuss Christopher's care and 11 treatment with Dr. Wilcox? 12 A. Often I do not discuss this with Dr. Wilcox unless he 13 requests that I come to discuss a particular patient with 14 him other than social amenities. 2:59P 15 Q. You have no independent recollection of having a 16 discussion with Dr. Wilcox regarding Christopher Morden's 17 care and treatment? 18 A. I have no independent recollection, that is correct. 19 Q. This isn't a memory test. You are welcome to look at the 20 medical records. 21 A. Unless I spoke to him about it on that particular day and 22 did what he requested, I did not document that I spoke 23 with him. I did document with whom I saw most of these 24 people and it looks like -- well, I have not documented 25 that I saw him. 95 1 Q. I may be wrong, but there is one part in the medical 2 record that says you may have assessed Christopher Morden 3 in the presence of Dr. Wilcox. 4 MR. GANO: I think that's in the presence of 5 Community Mental Health. 6 THE WITNESS: I don't think I ever saw any 7 patient in the presence of Dr. Wilcox. Bathroom break? 3:01P 8 MS. TUREK: Of course. 9 (Break was taken.) 3:15P 10 (Record read as follows: 11 2 Q. I may be wrong, but there is one part in the 12 medical record that says you may have assessed 13 Christopher Morden in the presence of Dr. 14 Wilcox.) 15 Q. (MS. TUREK) To your knowledge why weren't vital signs 16 provided to you? 17 MS. LYNN: Object to foundation. 18 THE WITNESS: I don't know. 19 Q. (MS. TUREK) Vital signs would be an important bit of 20 information in determining whether or not a patient is 21 having side effects to medications? 22 A. Are you asking are vital signs important? 3:23P 23 Q. Let me try again. When a patient is being provided with 24 psychotropic agents, assessment of vital signs is 25 important, correct? 96 1 A. Yes. 2 Q. And that's because abnormal vital signs may occur in 3 response to those medications, right? 4 A. Potentially, yes. 5 Q. For instance, an irregular pulse may occur, correct? 6 MR. GANO: You know, I'll object to it. It's 7 just asked and answered, I mean three hours ago, and I'll 8 instruct her not to answer. We're not going to go back 9 and cover the same stuff. 10 MS. TUREK: We're talking about vital signs. 11 MR. GANO: Pardon? 12 MS. TUREK: We're talking about vital signs now. 13 We've talked about what were side effects. Would you like 14 to review the record? Now we're talking about why are 15 vital signs important. 16 MR. GANO: And she's answered that. I think 17 you're saying -- wasn't your question irregular pulse is a 18 vital sign? 3:24P 19 Q. (MS. TUREK) Measurement of vital signs may indicate an 20 irregular pulse, right? I won't repeat myself. 21 A. So I wasn't listening to your question. 22 Q. Sure. Let's try it again. The reason you as a 23 psychiatrist would want to know what the vital signs are 24 is because -- and you've already answered this -- abnormal 25 vital signs may occur in response to a psychotropic drug, 97 1 right? 2 A. Yes. 3 Q. An irregular pulse is one of those vital signs that may 4 occur in response to a psychotropic drug, right? 5 MS. LYNN: Object to the form. 6 THE WITNESS: Yes. 7 Q. (MS. TUREK) Bradycardia is a vital sign that may occur in 8 response to a psychotropic drug, correct? 9 A. Yes. 10 Q. Fever is a vital sign that may be abnormal in response to 11 a psychotropic drug, right? 12 A. Yes. 3:25P 13 Q. You would agree that the standard of care requires the 14 psychiatrist to assess the vital signs when a patient is 15 being provided with two psychotropic drugs, correct? 16 MR. WIERDA: Objection, foundation. 17 Q. (MS. TUREK) You're a psychiatrist, right? 18 A. Yes. 19 MR. WIERDA: Okay. The objection is the amount 20 of information being provided for the hypothetical. 21 THE WITNESS: It's important for a psychiatrist 22 to know that the vital signs are stable. 23 Q. (MS. TUREK) In Christopher Morden's case, how could you 24 know if the vital signs were stable if you didn't know 25 what the vital signs were? 98 1 A. I refer back to charting by exception. 2 Q. Your assumption as a psychiatrist would have been that 3 vital signs were normal? 4 A. Yes. 5 Q. And Christopher was only given atypical antipsychotic 6 agents, correct? 3:26P 7 A. No. 8 Q. Typical and atypical, correct? Forgive me. Well, he was 9 given the antidepressant, also. 10 A. Yes. Thank you. 11 Q. So Christopher was provided with atypical antipsychotics 12 and an antidepressant, right? 13 A. Yes. 14 Q. Atypical antipsychotics given in conjunction with one 15 another; for instance, two at a time, potentiate the 16 effects of one another, correct? 17 MR. GANO: Did you say potentiate? 18 MS. TUREK: Potentiate. 19 MR. GANO: Thank you. 20 THE WITNESS: Sometimes. 21 Q. (MS. TUREK) So the standard of care for the psychiatrist 22 is to be vigilant in assessing for side effects -- strike 23 that. I will try again. When a patient is being provided 24 with two antipsychotics, both of which had the potential 25 to potentiate one another, the standard of care for the 99 1 psychiatrist requires an increased vigilance with regard 2 to assessing for side effects, right? 3:27P 3 MR. GANO: Counsel -- counsel are we again 4 agreeing that this is restricted in the environment of a 5 psychiatrist seeing an inmate in a jail on consultation 6 basis? 7 MS. TUREK: Well, I guess I would say this is 8 everywhere. 9 Q. (MS. TUREK) Anywhere you treat a patient you should be 10 monitor for side effects of the medications, correct? 11 A. I personally would be more vigilant in my private practice 12 where I am solely responsible as opposed to having 13 ancillary personnel available to me. 14 Q. In this setting -- when I say this setting, the jail 15 setting -- when you're using the term ancillary staff, you 16 include Dr. Wilcox in that group, right? 3:28P 17 A. Yes. 18 Q. The odds of an adverse outcome when a patient is being 19 provided with only one antipsychotic medication is not as 20 great as when the patient is being provided with two 21 antipsychotic medications, true? 22 A. Correct. 23 Q. And if you throw into that mix an antidepressant, the odds 24 of an adverse outcome are even greater, correct? 25 A. Correct. 100 1 Q. An adverse outcome for all of the questions that we just 2 talked about within the last three, four questions include 3 NMS, correct? 3:29P 4 A. Correct. 5 Q. You had said earlier that muscular rigidity is a result of 6 rhabdomyolysis? 7 A. No. 8 Q. Forgive me then. The muscular rigidity is from the 9 blockade of dopamine neurotransmission, correct? 10 A. (Nodding head up and down.) 11 Q. Is that a yes? 12 A. Yes. 13 Q. And the reason that there is a decreased mortality rate, 14 and that mortality you said was 50 percent, the reason 15 there is a decreased mortality rate from NMS is that there 16 are more efforts at prevention of the syndrome, correct? 17 MR. GANO: Always opposed to what? 18 MS. TUREK: As opposed to when the mortality 19 rate was 50 percent. 20 MR. GANO: Are we talking about atypical drugs 21 or typical drugs? 22 MS. TUREK: That's the reference -- that's what 23 I gave you yesterday. I like to play by the rules. 24 What's the legal objection? 25 MR. GANO: Lacking in form and foundation. 101 3:30P 1 MS. TUREK: Okay. 2 Q. (MS. TUREK) You testified earlier that the mortality rate 3 was once 50 percent with NMS, correct? 4 A. (Nodding head up and down.) 5 Q. Yes? 6 A. Yes. 7 Q. The mortality rate has significantly decreased as a result 8 of efforts at prevention of the development of NMS, 9 correct? 10 A. The mortality rate has decreased because of the 11 neuroleptic medications available to us and increased 12 surveillance. 13 Q. And when you say increased surveillance, that means 14 increased monitoring for side effects of the antipsychotic 15 medications, right? 16 A. Increased awareness on medical professionals to look for 17 symptoms associated with NMS. 18 Q. And you expect the nurses that care for your patients to 19 watch for NMS, correct? 3:31P 20 A. I expect the nurses who care for my patients to watch for 21 any abnormalities. 22 Q. You expect that the physician who has consulted you to 23 watch for any abnormalities as well, right? 24 A. As primary physician for that patient, he's ultimately 25 responsible for any adverse effects. 102 1 Q. You would agree that death from NMS is usually caused by 2 respiratory failure, cardiovascular collapse, 3 myoglobinuria, renal failure, arrhythmias, or DIC, right? 4 A. Those are some of the reasons why people succumb to NMS. 5 Q. The myoglobinemia can be tested with a simple blood test, 6 right? 3:32P 7 A. Simple? It can be tested with a blood test, yes. 8 Q. And the blood test is easily obtained in Grand Traverse 9 County? 10 A. Yes. 11 Q. And the urine test for myoglobinuria, is that something 12 that's easily obtained? 13 A. I'm not familiar with what the pathology lab can and 14 cannot do. 15 Q. Have you ever sent a patient for myoglobin in their urine 16 for testing? 17 A. I personally have not. 18 Q. Have you ever sent a patient for testing of myoglobin 19 serum? 20 A. Yes. 21 Q. Is that more reliable? 22 A. Each piece of the puzzle goes to make up the whole of the 23 puzzle. 24 Q. The standard of care in 2002 was not to obtain a baseline 25 serum myoglobin, correct? 103 3:33P 1 A. Correct. 2 Q. Is the standard of care now in 2005 to obtain a baseline 3 myoglobin level serum? 4 MR. GANO: I'll object to relevance. 5 THE WITNESS: It never was and continues not to 6 be the standard of care to obtain a baseline level, no. 7 Q. (MS. TUREK) It is the standard of care for a psychiatrist 8 to have the patient medically cleared prior to ordering 9 psychotropic medications, right? 10 A. Yes. 11 Q. You'd agree that the standard of care prior to prescribing 12 antipsychotropic (sic) medications that prolong the QT 13 segment should include a baseline EKG? 14 MR. GANO: Asked and answered. 15 MS. LYNN: Object to the form. 16 THE WITNESS: Yes. 17 Q. (MS. TUREK) Was a baseline EKG done on Christopher 18 Morden? 3:34P 19 A. I don't know. 20 MR. GANO: Can we go back and read back that 21 last question about the standard of care and the EKG, 22 please? I'm not sure I got the right question. 23 (Record read as follows: 24 3 Q. You'd agree that the standard of care prior 25 to prescribing antipsychotropic (sic) 104 1 medications that prolong the QT segment should 2 include a baseline EKG?) 3:35P 3 Q. (MS. TUREK) You would agree, Doctor, that if the patient 4 is already on one drug that prolongs the QT segment and 5 another drug is added onto the patient's regimen that also 6 prolongs the QT segment, standard of care provides that an 7 EKG be performed? 8 MS. LYNN: Objection to form and foundation. 9 THE WITNESS: If that were the case, I agree 10 with that. 11 Q. (MS. TUREK) Risperdal can prolong the QT segment, right? 12 A. Risperdal typically does not prolong the QT segment. 13 Q. Well, I understand that it doesn't typically, but it 14 can -- I mean one would -- would it be a side effect? 3:38P 15 A. It would be a rare event. 16 Q. A rare event. Risperdal is known -- strike that. 17 Risperdal has the potential to prolong the QT segment, 18 correct? 19 MS. LYNN: Asked and answered. 20 THE WITNESS: Anything is possible. 21 Q. (MS. TUREK) Janssen is one of the drugs or is the company 22 that manufactures Risperdal, right? 23 A. Yes, ma'am. 24 Q. You spoke on Risperdal, right? 25 A. Yes, ma'am. 105 1 Q. You spoke on the cost benefit analysis of Risperdal, 2 right? 3 A. Yes, ma'am. 4 Q. You know that Risperdal can lengthen the QT segment 5 interval, right? 6 A. It's a rare event. In fact, their brochure is a proponent 7 to using its drugs as opposed to other drugs that do do 8 that. 3:39P 9 Q. That do prolong the QT segment. Prolonging the QT segment 10 can increase the risk for arrhythmia, right? 11 A. Yes, ma'am. 12 Q. You had talked about Torsades de Pointes? 13 A. Yes, ma'am. 14 Q. That's life-threatening, Torsades de Pointes, right? 15 A. Yes, ma'am. 16 Q. Arrhythmia, cardiac arrhythmias are life-threatening, 17 right? 18 A. Yes, ma'am. 19 Q. QT segment prolongation is life-threatening, correct? 20 A. Not necessarily. 21 Q. But can be, right? 22 A. Absolutely. 23 Q. Celexa causes QT prolongation sometimes, too, right? 24 A. As a rare event. 25 Q. Celexa also causes ventricular arrhythmia sometimes? 106 1 A. As a rare event. 3:40P 2 Q. So Celexa in combination with Risperdal requires that the 3 psychiatrist under the standard of care makes sure that 4 the QT segment is not prolonged, correct? 5 MR. GANO: I object to the form of the question. 6 I'm not sure what you mean when you say makes -- are you 7 saying required by the standard of care. 8 MS. TUREK: You know what. I know what your 9 objection is and I'm not going to correct my question. I 10 appreciate you testifying, but, come on now, I didn't do 11 that yesterday. 12 Q. (MS. TUREK) Go ahead, Doctor. Do you want the question 13 read back? 14 A. Yes. I'm confused at this point. 15 MR. GANO: Counsel, I'm allowed to state the 16 basis for my objection to form and foundation. 17 MS. TUREK: I know. 18 MR. GANO: So don't give me the naughty finger 19 sign. Let's just get on with it. We've been here for 20 four hours now. 3:42P 21 MS. TUREK: I think what would be a good idea 22 since we're just starting out in this whole process is if 23 we practiced under the rules and the rules are your legal 24 objection, not testifying or your comments. 25 MR. GANO: I'm stating the basis for my 107 1 objection which I'm permitted to do. 2 MS. TUREK: I understand but, you know, coaching 3 the witness on the record is not a good thing and it's not 4 allowed. 5 MR. GANO: Did you have a question? 6 MS. TUREK: We're waiting to have it read back 7 to the doctor. 3:43P 8 (Record read as follows: 9 4 Q. So Celexa in combination with Risperdal 10 requires that the psychiatrist under the 11 standard of care makes sure that the QT segment 12 is not prolonged, correct?) 13 THE WITNESS: Given these two medications and 14 given the fact that the patient came to me on these two 15 medications, I do not believe we would be justified in 16 incurring further expense in getting an EKG. 3:44P 17 Q. (MS. TUREK) How much does an EKG cost, Doctor? 18 A. I don't know. 19 Q. Is it thousands of dollars? 20 A. I don't know. 21 Q. It's pretty inexpensive, isn't it, Doctor? 22 A. I don't know. 23 Q. Then how could you say you could not justify the expense 24 if you don't know what the expense is? 25 MR. GANO: I object to the form of the question. 108 1 It's argumentative. 2 THE WITNESS: I can't justify ordering any test 3 that I do not have reasonable need for. The patient came 4 to me on these two medications, had been stable on these 5 two medications for quite sometime, and consequently I 6 believed that would continue. 7 Q. (MS. TUREK) Is that your understanding of NMS, that once 8 the patient has been on the medications for a couple 9 months that there's absolutely no possibility of NMS 10 occurring? 11 A. No. That's not my understanding of NMS. 3:45P 12 Q. Is it your understanding that QT prolonged elongation 13 cannot occur three months after the medications have been 14 in place on a patient? 15 A. It's my understanding that QT changes happen pretty early 16 on and years later it's not likely to happen. 17 Q. Isn't it your understanding also that QT segment 18 elongation can occur when the dosing of the drug is 19 increased? 20 A. That is a possibility. 21 Q. You increased one of these medications on Christopher, did 22 you not? 23 A. Yes, ma'am, I did. 24 Q. He was then at risk for QT elongation, correct? 3:46P 25 A. Potentially, he was. 109 1 Q. Is it your understanding, Doctor, that myoglobin will show 2 up in the serum before it shows up in the urine? 3 A. That question is impossible to answer as asked. 4 Q. Well, it's not the urinary bladder muscle that breaks 5 down, right? 6 A. The body is in constant turnover. 7 Q. Myoglobin in the urine is not a normal finding, correct? 3:47P 8 A. Myoglobin that is detectable in the urine is not a common 9 finding. 10 Q. You would agree, Doctor, that if the muscle starts to 11 break down anywhere in the body, the first place that it 12 would be detectable is in the serum, correct? 13 A. Yes. 14 Q. And it would have to reach a certain level before it 15 spilled into the urine, correct? 16 A. Correct. 17 Q. And so muscle breakdown throughout the body -- strike 18 that. Muscle breakdown anywhere in the body doesn't 19 immediately send myoglobin into the serum, correct? 20 A. There is a certain amount of myoglobin in the serum all 21 the time in a normal person. 22 Q. And at some point in time sometimes the myoglobin level in 23 the serum becomes elevated; i.e., abnormal, right? 3:48P 24 A. Correct. 25 Q. And the way myoglobin gets into the urine is via the serum 110 1 through the kidneys, correct? 2 A. It's filtered from the blood through the glomerular 3 apparatus into the urine. 4 Q. Is that why you test for an elevated myoglobin level via 5 the serum and not via the urine? 6 A. I imagine that's true. 7 Q. Is urine myoglobin -- an elevated urine myoglobin or a 8 detectable urine myoglobin would be a late sign of an 9 elevated serum myoglobin, correct? 3:49P 10 A. Of any cause, yes. 11 Q. Why don't you tell the people in here why Christopher's 12 urine myoglobin is not attributable to the seizure he had 13 just prior to his death? 14 MR. GANO: Objection, form and foundation. 15 MR. WIERDA: I object. 16 MR. GANO: I object and instruct the witness not 17 to answer. Do you want to rephrase the question to ask 18 something other than why don't you tell the people here? 19 Q. (MS. TUREK) It's on pleadings, Doctor. I'm sorry. They 20 know this. You probably don't. It's on their pleadings 21 that that's why the myoglobin is increased in his urine or 22 detectable in his urine at autopsy. So it's just being 23 polite. 24 A. I'm not aware that he had myoglobin in his urine. 25 Q. Oh, okay. 111 1 A. So I couldn't comment as to cause. 3:50P 2 Q. Sure. Rhabdomyolysis occurs on a spectrum, correct? 3 A. Yes. 4 Q. Or a continuum? 5 A. Yes, ma'am. 6 Q. What's the difference, I wonder? 7 A. I believe it's semantic. 8 Q. Thank you. 9 MS. LYNN: I'm sorry. You believe what? 10 THE WITNESS: It's semantic. 11 Q. (MS. TUREK) In risk factors for developing NMS are 12 increased ambient temperature, right? 13 A. It is a risk factor. 14 Q. Are you aware of what the temperature was in the rooms 15 that Christopher Morden was frequenting during the last 16 week of his life? 17 A. No, I'm not. 18 Q. Were you aware of whether or not Christopher was 19 dehydrated during the last week of his life? 20 A. No, I'm not. 21 Q. Are you aware of whether or not Christopher was agitated 22 during the last week of his life? 23 A. No, I'm not. 24 Q. Were you aware of whether or not Christopher was catatonic 25 during the last year of his life? 112 3:51P 1 A. No, I'm not. 2 Q. An increased ambient temperature, dehydration, agitation, 3 catatonia, these are all risk factors for developing NMS, 4 correct? 5 A. Yes. 6 Q. All of the same questions with regard to the time period 7 within which you encountered Christopher Morden, were you 8 aware the jail or the temperature in the rooms within 9 which Christopher frequented? 10 A. No, ma'am, I'm not. 11 Q. Were you aware whether or not Christopher was dehydrated? 12 A. No, I'm not. 13 Q. I'm sorry. Were you aware whether or not Christopher was 14 dehydrated within the time period within which you were 15 treating Christopher? 16 A. No, I was not aware. 17 Q. You assumed that he was not dehydrated because he was 18 under the care of Dr. Wilcox, right? 19 MS. LYNN: Object to form. 20 THE WITNESS: I had not received any report that 21 there were any abnormal vital signs with regard to Mr. 22 Morden. 23 Q. (MS. TUREK) And you had not received any reports that he 24 was dehydrated, right? 3:52P 25 A. Correct. 113 1 Q. And you had not received any reports that he was well 2 hydrated, right? 3 A. Correct. 4 Q. And dehydration -- we already said that. Okay. And you 5 would agree concomitant use of NMS predisposing drugs is 6 one of the risk factors for developing NMS, right? 7 A. Yes, ma'am. 8 Q. Risperdal can cause NMS, yes? 9 A. Yes. 10 Q. Seroquel can cause NMS? 11 A. Yes. 12 Q. Celexa can cause NMS? 13 A. Yes. 14 Q. Rapid initiation of dose escalation of one of those three 15 drugs can cause NMS, right? 16 A. Yes. 17 Q. NMS is most common in males, correct? 18 A. Yes, ma'am. 19 Q. In fact, the male to female ratio is 2:1, correct? 3:53P 20 A. I believe that's correct. 21 Q. There's to age predilection for NMS, right? 22 A. I think younger men are more susceptible. 23 Q. And Christopher was a younger man, right? 24 A. Yes, ma'am. 25 Q. NMS is more likely to develop following the initiation of 114 1 antipsychotic medication therapy, right? 2 A. Yes, ma'am. 3 Q. It's more likely to develop following an increase in 4 dosage of an antipsychotic, correct? 5 A. Yes, ma'am. 6 Q. You would agree that if there is early recognition and 7 aggressive treatment of NMS, there is only a five percent 8 mortality rate? 9 A. Yes, ma'am. 10 Q. You would agree that NMS spans a broad severity continuum? 11 A. Yes, ma'am. 12 Q. The diagnosis of NMS is based on clinical grounds, 13 correct? 14 A. Could you define clinical grounds? 3:54P 15 Q. Sure. Historical, physical, and lab findings? 16 A. Yes, ma'am. 17 Q. All right. You didn't have access to lab findings when 18 you were treating Christopher, right? 19 A. No, ma'am. 20 Q. And that's because labs were not ordered on Christopher 21 during the time period you were treating him, correct? 22 MR. WIERDA: Objection, foundation. 23 THE WITNESS: I do not know if they were 24 ordered. I did not order any. 25 Q. (MS. TUREK) Did you observe any lab findings at any visit 115 1 you had with or regarding Christopher? 3:55P 2 A. If I received and reviewed lab findings, I would make a 3 note in my documentation. I will check to see if that's 4 so. According to my documentation, no lab findings were 5 reviewed with regard to Mr. Morden. 6 Q. Can you look through the record one more time, Doctor? 7 I'm understand you're saying that they were not reviewed. 8 Were they available to you as you can see from the medical 9 record in front of you? 10 MS. LYNN: Available as in performed and 11 reported on or available as in could have been ordered and 12 obtained? 13 MS. TUREK: Thank you. 14 Q. (MS. TUREK) Available as in performed and reported. 15 MS. LYNN: Thank you. 3:56P 16 THE WITNESS: I do not know if they were 17 ordered. I did not review them. I do not know of their 18 existence. I would presume that's under the purview of 19 his primary care doctor. 20 Q. (MS. TUREK) Are you saying, Doctor, that the standard of 21 care does not require the psychiatrist to order any lab 22 work when the patient is being provided with three 23 medications; specifically two antipsychotics and one 24 antidepressant? 25 A. If there were abnormal labs, I would hopefully be made 116 1 aware of those. If these were medications that required 2 monitoring, then those lab reports would be given to me 3 for my edification and they would be documented on my 4 paperwork that they were reviewed. These three 5 medications, other than baseline laboratory, do not 6 require follow-up evaluations other than every six months, 7 every year. 3:57P 8 Q. You would agree, Doctor, the standard of care requires 9 more than just baseline labs if the patient is exhibiting 10 any signs/symptoms of adverse effects of the medications, 11 right? 12 MS. LYNN: Object to form. 13 MR. GANO: I will join. 14 MS. LYNN: It's vague. 15 THE WITNESS: It depends on what those adverse 16 events are. 17 Q. (MS. TUREK) I'm going to give you a constellation of 18 signs and symptoms if I may. This is a hypothetical. If 19 the patient has delayed speech, slow speech. 20 MR. GANO: Before we go through this, you're 21 asking in the form of a hypothetical to assume these all 22 exist at the same point in time? 3:58P 23 MS. TUREK: Let me clean it up then. 24 MR. GANO: Thank you. 25 Q. (MS. TUREK) Doctor, I'm giving you a hypothetical and 117 1 assume the patient has exhibited the following signs 2 and/or symptoms and/or findings over an one-month period; 3 if the patient has delayed and slowed speech; if the 4 patient complains of dizziness; if the patient complains 5 of blackouts whenever he stands up; if the patient states 6 that he has to hold onto a wall to stop himself from 7 falling; if the patient says that the dizziness started 8 the last time the Risperdal was increased; if the patient 9 is losing weight; if the patient is complaining of 10 tingling all over his chest; if the patient is complaining 11 of head rushes, you would agree -- or if the patient is 12 walking stiffly, you would agree, Doctor, that the 13 standard of care would require that the psychiatrist order 14 lab work? 3:59P 15 MR. GANO: You have to understand she's not 16 asking you about Christopher Morden. She is asking you to 17 assume a hypothetical patient who presents with all that 18 constellation of symptoms as I understand your question 19 all at the same point of time. 20 MS. TUREK: No. Within one month is what I said 21 in the beginning. 22 MR. GANO: And can you describe -- 23 MS. TUREK: No. that's the question. Come on, 24 Charlie. 25 THE WITNESS: I can answer that. If a patient 118 1 came to me with those symptoms, I would refer him to the 2 emergency room for a medical clearance. 4:01P 3 Q. (MS. TUREK) Why? 4 A. Because I wouldn't know the etiology of all those 5 symptoms. They are across the gambit. They could be most 6 anything and I would need to know if he was medically 7 stable. 8 Q. They can also be signs, symptoms, and/or findings of NMS, 9 correct? 10 MR. WIERDA: Objection, form and foundation. 11 Q. (MS. TUREK) Let me try over. All the signs and symptoms 12 in my last question, that hypothetical, every one of them 13 could be a sign, symptom, and/or finding of NMS, correct? 14 MR. GANO: In any one of them individually? 15 Q. (MS. TUREK) Every one of them. 16 A. A constellation? 4:02P 17 Q. Yes, correct. 18 A. I would not jump to a diagnosis of NMS if those symptoms 19 were presented to me which is why I would send him for a 20 medical clearance because they are quite disparate. 21 Q. And disparaging why? 22 MR. GANO: Disparate, not disparaging. 23 MS. LYNN: What was the word? 24 MS. TUREK: That's because you're talking to 25 your client and I'd rather not have the transcript read 119 1 back every time that happens. 2 MS. LYNN: I wasn't talking to my client just 3 now when she said that word. I just didn't hear the word. 4 I'm sorry. She's facing your direction when she's 5 testifying. I don't always hear it. 6 MS. TUREK: I must be hallucinating, too. 7 MS. LYNN: Just now she said a word and I was 8 turned this way in fact, but I didn't hear the word. 9 MS. TUREK: I think she said it twice and it's 10 disparate, right, Doctor? 11 THE WITNESS: Yes, ma'am 12 MS. LYNN: Disparate. Thank you. 13 Q. (MS. TUREK) What do you mean by disparate? 14 A. Some of them sound like potential hypotension. Some of 15 them sound like they could be due to an electrolyte 16 abnormality. Some of them sound like they could be due to 17 extrapyramidal side effects, symptoms. And as a lone 18 practitioner, I would ask for assistance. 4:03P 19 Q. An electrolyte imbalance predisposes the patient to NMS, 20 right? 21 A. Yes, ma'am. 22 Q. Hypotension is one of the side effects of the medications 23 that Christopher was taking, right? 24 A. Yes. 25 Q. Hypotension is one of the findings in NMS, correct? 120 1 A. Can be. 2 Q. Postural hypotension is one of the effects of medications 3 that Christopher was getting, correct? 4 A. Yes, ma'am. 5 Q. Postural hypotension in a patient's words could include I 6 have to hold onto the wall when I stand up to stop from 7 falling down, right? 4:04P 8 A. Yes, ma'am. 9 Q. Postural hypotension can be from -- strike that. Postural 10 hypotension can make the patient believe they're dizzy, 11 right? 12 A. Yes, ma'am. 13 Q. Postural hypotension can make the patient describe head 14 rushes, right? 15 A. Yes. 16 Q. Increased muscle tone would evidence itself as a patient 17 walking stiffly, correct? 18 A. Increased muscle tone? 19 Q. Yes, ma'am. Not yet rigid. Just increased muscle tone. 20 A. Potentially. 21 Q. So if a patient is walking stiffly, he may have increased 22 muscle tone, right? 4:05P 23 A. Potentially. 24 Q. An increased muscle tone is increased sign of NMS, right? 25 A. Yes, ma'am. 121 1 Q. A urinalysis was not ordered to your knowledge on 2 Christopher, right? 3 A. Yes, ma'am. 4 Q. Dark brown urine may be a sign of NMS, right? 5 A. Dark brown urine could be a sign of a lot of things, NMS 6 being one of them. 4:06P 7 Q. Dark brown urine in the presence of NMS is from urine 8 myoglobin, right? 9 A. More than likely, yes. 10 Q. Risperdal causes an electrolyte imbalance, right? 11 A. Not commonly. A rare event. 12 Q. Every time you have used the phrase a rare event, it's 13 something that you have known of with regard to Risperdal, 14 Seroquel, and Celexa, right? 15 MR. GANO: Well, I'm going to object to the 16 question. It's overly broad and vague. 17 THE WITNESS: I have reviewed at least once all 18 the potential side effects, both frequent and likely as 19 well as infrequent as well as rare. These are categorized 20 by the FDA with percentages when compared with placebo. 4:07P 21 Q. (MS. TUREK) And I guess what you're saying is that every 22 single maloccurrence that occurs after a drug may be 23 attributable to the drug by the FDA in a certain 24 percentage? 25 A. Yes, ma'am. As I said previously, I never say no to a 122 1 patient. Potentially, it's true. 2 Q. How do you explain -- you know that hypothetical I gave 3 you. 4 A. Yes, ma'am. 5 Q. All of those things are written in Christopher's medical 6 records, all those things I said to you. 7 MR. WIERDA: Objection. 8 MS. TUREK: What objection? 9 MR. WIERDA: It's not a true statement. 4:08P 10 MS. TUREK: Which one wasn't in there? 11 MR. WIERDA: I don't have them directly in front 12 of me. As you were going through them, I believe you were 13 absolutely misquoting and they're aren't in all the 14 medical records. 15 MR. GANO: And I will object to foundation. 16 Q. (MS. TUREK) Assume, Doctor, that Christopher Morden had 17 all those signs and/or symptoms for the one month 18 preceding his death, you would agree that he needed some 19 type of lab studies? 20 A. Unless -- 21 MR. WIERDA: Objection. 22 THE WITNESS: -- unless an alternative 23 explanation made better sense. 24 Q. (MS. TUREK) There was a no alternative explanation for 25 what was happening with him, right? 123 1 A. No, ma'am, I do not agree with you. 2 Q. Oh, go ahead. Why don't you agree? 3 A. I believe some of the symptoms that he reported to various 4 practitioners were due to his mental illness. 5 Q. Which ones were attributable to his mental illness? 6 A. The characterization of the head rush, tingling all over 7 from the chest, made its way out. That's a quote from Mr. 8 Morden. And I believe those were things that you were 9 referring to. 4:09P 10 Q. The head rushes and the -- 11 A. And the tingling all across the chest. 12 Q. The head rushes I thought we agreed that that could be 13 evidence of postural hypotension? 14 A. Yes, we did agree to that. 15 Q. Okay. In Christopher's case, you think his head rushes 16 were not attributable to postural hypotension? 17 A. Potentially they could be or they could be a manifestation 18 of his mental illness. That's where the art of medicine 19 comes in. 20 Q. Another cause; i.e., NMS, was not ruled out in 21 Christopher's case, was it? 22 MR. GANO: I'm sorry. When? 23 Q. (MS. TUREK) Go ahead. 4:10P 24 MR. WIERDA: I'll join the objection. 25 Q. (MS. TUREK) Go ahead. 124 1 A. I never have and continue to believe that Christopher was 2 not suffering from NMS. 3 Q. You believe he was not suffering from NMS? 4 A. Right. 5 Q. Why? Why do you believe that? What's the basis? 6 A. The cascade of symptomatology doesn't fit a typical NMS 7 picture although I would be willing to entertain the fact 8 that I might be wrong. 9 Q. And that's based on your statement earlier that you saw an 10 NMS patient who did not have one the classic signs? 11 A. Yes, ma'am. One must always be willing to be wrong. 12 Q. You would agree that the diagnosis of NMS is confirmed but 13 not necessarily excluded by the presence of five criteria, 14 right? 4:11P 15 A. I actually have not reviewed the literature regarding NMS 16 as directed by my lawyer. Therefore, I'm going upon 17 clinical practice and clinical acumen. And his cluster of 18 symptomatology did not lead me in the direction of NMS but 19 instead perhaps some hypotension which is a known symptom 20 of some of these medications as well as a lack of efficacy 21 of the psychotropic medications that would be an 22 exacerbation of his paranoid schizophrenia and later found 23 out in fact he was not taking his medications but refusing 24 some which would account for many of these symptoms that 25 he's reporting. 125 4:12P 1 Q. On what basis do you make the statement that Christopher 2 was refusing his medication? 3 A. On documentation provided to me. 4 Q. What documentation was that? 5 A. Jail documentation. 6 Q. Can you point me to the documentation that says he was 7 refusing his medication? 8 MR. GANO: Off the record 4:15P 9 (Off-the-record discussion.) 10 MR. GANO: Okay. We're ready. 11 MS. TUREK: Thank you. Could you read back the 12 question, please? 13 (Record read as follows: 14 5 Q. On what basis do you make the statement that 15 Christopher was refusing his medication? 16 A. On documentation provided to me. 17 6 Q. What documentation was that? 18 A. Jail documentation. 19 7 Q. Can you point me to the documentation that 20 says he was refusing his medication?) 4:16P 21 Q. (MS. TUREK) Go ahead, Doctor. 22 A. On 3-6 of '02 the patient was seen by Jim Talbott who 23 records that Deputy Cederquist called to let CMH know that 24 CM decided not to take his meds again tonight. 25 Apparently, this has been occurring recently on an every 126 1 other night basis. CM claims that voices told him not to 2 take his meds. 3 And I also reported on my paperwork that per the 4 patient's quote, "I'm on medical observation...didn't take 5 my medicines." 6 Q. And that was on March 12th, right? 7 A. Yes, ma'am. And this was on the 6th. 8 Q. After the 6th is when Christopher started complaining of 9 dizziness and blackouts whenever he stood up. On March 10 19th he began complaining of head rushes. On March 23rd 11 when you saw him, he started complaining that he would get 12 a head rush when he would stand up, and that he had to 13 hold onto the wall to keep from falling from the floor -- 14 or falling to the floor, beg your pardon. Is there any 15 time between March 6th and March 23rd that Christopher had 16 refused his medications? 4:17P 17 MR. WIERDA: Objection, form and foundation. 18 MR. GANO: I'm sorry. Between March -- 19 MS. TUREK: 6th and 23rd. 20 MR. GANO: So you want us to look through each 21 of the... 22 MS. TUREK: I guess I want to know what the 23 doctor knew at the time. 4:18P 24 THE WITNESS: At the time that I saw him on 25 3-12, I noted that he did not take his medications, but I 127 1 did note that there was some improvements on neuroleptics, 2 and recommended that we increase the Risperdal to two 3 milligrams t.i.d. knowing that it's within the spectrum of 4 schizophrenia that patients not consistently take their 5 medications. On occasion they can be medicated to the 6 point and cross over to where they are much more 7 voluntarily compliant with taking their medications on a 8 regular basis. Often if you don't have enough medications 9 on board, patients will continue to refuse; ergo, the 10 development of depo preparations. 4:20P 11 Q. If you thought that Christopher wasn't taking his 12 medications appropriately, you would have ordered depo 13 preparations, right? 14 A. No, ma'am. 15 Q. Then what did your last answer mean? 16 A. That's the reason why depo preparations were brought into 17 existence was because patients tend not to take their 18 medicines on a regular basis. In a controlled environment 19 such as a jail, you know when the patients are and are not 20 taking their medications and consequently you work with 21 giving them daily medications. Risperdal in 2002 does not 22 come as a depo preparation. Only typicals, Haldol and 23 Prolixin, come as depo preparations, therefore, losing the 24 potential gains of giving them atypical versus a typical. 4:21P 25 Q. Is there anywhere in the record after March 6th that 128 1 reveals Christopher was refusing his medications? I'm 2 sorry, Doctor, to interrupt you. That would be the record 3 that you had access to while you were caring for and 4 treating Christopher. 5 A. I document on 3-12 that he stated to me he did not take 6 his medicines. 7 Q. On 3-12 did you have access to the other record that you 8 pointed to March 6th saying that he was not taking his 9 medications as prescribed? 10 A. I don't remember. 11 Q. I guess I'm trying to figure out how is it you would 12 attribute his signs, symptoms, and findings to him not 13 taking his medications versus NMS? 4:22P 14 A. The more likely explanation, more reasonable explanation 15 is that he is still in the throes of his mental illness 16 rather than developing a neuroleptic malignant syndrome. 17 Q. What sign, symptom, or finding would have prompted you to 18 suspect neuroleptic malignant syndrome? 19 MR. GANO: I'm sorry. What point in time? 20 Q. (MS. TUREK) March 23rd, the last time you saw him. 21 A. I would expect some cognitive difficulties if, in fact, he 22 had something as devastating as NMS. 23 Q. It's not devastating in the beginning, though, right? 24 A. It's usually a slow and insidious onset. 25 Q. Correct. So you wouldn't expect an impairment of 129 1 cognitive function in the beginning of NMS, would you? 4:23P 2 A. I would expect something. 3 Q. Isn't NMS a slow and insidious onset usually started out 4 with physical signs and symptoms. 5 MR. GANO: I'm sorry. So you mean the physical 6 signs and symptoms come first before the cognitive? 7 MS. TUREK: Right. Right. 8 THE WITNESS: Typically, Yes. 9 Q. (MS. TUREK) So an impairment of cognitive function might 10 be a late finding of NMS, correct? 11 A. There are some subtle changes that you can pick up on. 12 Q. In the beginning of NMS? 13 A. No. 4:24P 14 Q. You were called in -- strike that. You were provided with 15 information that somebody seeing Christopher at the jail 16 thought that his medication needed to be adjusted as a 17 result of the signs and symptoms, right? 18 MR. GANO: I'm sorry. At what point in time? 19 Which consult are you asking about? 20 Q. (MS. TUREK) Prior to your March 23 consult. Specifically 21 Dr. Wilcox recommended a psychiatric consult to evaluate 22 the medication change? 23 A. When? 24 Q. Prior to your visit on March 23rd. 4:25P 25 A. I do not know what Dr. Wilcox was thinking during the time 130 1 he wrote his note. 2 Q. Was it your understanding that at your visit on March 23rd 3 that somebody in the realm of Christopher's world thought 4 there was a problem with the medications? 5 MR. GANO: Let me object to the form of the 6 question. Realm of Christopher's world? 7 MS. TUREK: Somebody, meaning a human being, 8 that had encountered Christopher. 9 MR. GANO: I object to the form of the question 10 as argumentative. 4:26P 11 Q. (MS. TUREK) Rather than list out the numerous categories 12 and capacities of the individuals, Doctor -- 13 MR. GANO: We've got the foundation. Give me 14 the question again, please. 15 MS. TUREK: Sure. 16 Q. (MS. TUREK) Was it your understanding at your visit on 17 March 23rd that somebody thought that there was a problem 18 with the medications that were being provided to 19 Christopher? 20 A. Given my response on my consultation of 3-23, I would 21 believe that, yes, somebody somewhere, including myself, 22 thought that the medications should be changed. 23 Q. And to your knowledge why did somebody somewhere think the 24 medications should be changed? 4:27P 25 MS. LYNN: Objection to the form. 131 1 THE WITNESS: There are multiple possibilities 2 why those medications should be changed, but the one that 3 looks like it would be most likely is that one of the 4 medications was not effective, number one; and, number 5 two, it was potentially causing side effects. So for 6 those two reasons, a medication change would be 7 recommended. 8 Q. (MS. TUREK) And then you mention that you thought the 9 medications should be adjusted or changed, right? Just 10 now I'm talking about now. Not in the medical records. 11 You said somebody else thought it and you thought also 12 that he should be re-evaluated? 4:28P 13 A. I included myself in any human being. 14 Q. Okay. You thought the medications also should be adjusted 15 when you saw Christopher on the 23rd? 16 A. From the complaints that he gave me, I thought perhaps 17 orthostatic hypertension was the culprit. And given my 18 limited choices of antipsychotics, I chose the second best 19 medication for him and started a cross taper. 20 Q. The postural hypotension could have been indicative of 21 NMS, correct? 22 A. Yes, ma'am, it could have been. 23 Q. You did nothing to rule out NMS, correct? 24 A. Not that I have documented. 25 Q. Other than what you have documented, did you do anything 132 1 to rule out NMS? 2 A. I typically check patients if they complain for any 3 cogwheeling. I did not note that there were no 4 psychomotor changes here; therefore, I cannot state that I 5 did that in this case. 4:29P 6 Q. So you did not do anything to rule out NMS in 7 Christopher's case on March 23rd, correct? 8 A. That would appear to be the case. 9 Q. Why not? 10 A. I at that point in time and continue to believe that NMS 11 was not a problem in this patient. 12 Q. Why do you think he died? 4:30P 13 A. I believe that's in the realm of the pathologist. 14 Q. What is your opinion as to why he died? 15 A. Can I speculate? 16 MR. GANO: No. You're not allowed to speculate. 17 THE WITNESS: It would be speculation. 18 Q. (MS. TUREK) And it's also speculation to believe that he 19 did not die from NMS, right? 20 MR. GANO: I'll object to the form of the 21 question as argumentative. 22 Q. (MS. TUREK) I'm not arguing with you, Doctor. 23 MR. GANO: Sure you are. Go ahead and answer 24 the question if you know. 25 MS. TUREK: She knows I'm not. You should go 133 1 ask your client. 2 THE WITNESS: I do not believe that the cascade 3 of symptoms he's displaying are sufficient to entertain a 4 diagnosis of NMS. Is it possible? Anything is possible. 5 Is it likely? Highly unlikely. 4:31P 6 The more likely explanation, as I said before, 7 is that it's an exacerbation of his psychotic disorder and 8 that he needs more antipsychotic medication which flies in 9 the face of it potentially being NMS. I never would have 10 started a cross hydration of any of these medications if I 11 felt IT was not in his best interest and I felt that he 12 was at risk for NMS. The treatment for NMS is to 13 discontinue all psychotropic medications and stabilize the 14 patient. First aid. 15 Q. The patient is in critical condition if they have NMS, 16 correct? 17 A. There is a spectrum, a continuum of NMS. We have treated 18 them where there has been a slight elevation of CPK levels 19 where just a modicum of changes in autonomics who have had 20 their medications lowered and done quite well. There are 21 other people who have been admitted to the intensive care 22 unit and put on drugs such as Bromocriptine. It's a 23 spectrum and treated according to what the clinical signs 24 and symptoms tell you what to do. 4:32P 25 Q. You would agree, Doctor, that NMS can progress from onset 134 1 to death within 72 hours, right? 2 A. It's been known to do that. 3 Q. And you would agree, Doctor, that the treatment of NMS 4 includes transfer to an acute care medical facility where 5 intensive monitoring is available? 4:33P 6 A. Yes, ma'am, if it's suspected. 7 Q. You would agree that the standard of care requires the 8 psychiatrist to include the NMS within the differential 9 when a patient is on two medications that not only 10 potentiate one another but in and of themselves cause NMS? 11 A. I don't believe that's the standard of care that you 12 entertain NMS whenever a patient is on two medications 13 that potentiate each other. That's not the standard of 14 care. 15 Q. You would agree that the standard of care is to watch for 16 NMS when the patient is on -- 17 A. Any medication at any time. 18 Q. Were you ever involved in developing any policies and 19 procedures for the jail? 4:36P 20 A. No. 21 Q. Did you ever see any policies and procedures from the 22 jail? 23 A. Not that I recall. 24 Q. Are you aware of any policies and procedures at the jail 25 with regard to care and treatment of psychiatric patients? 135 1 A. I'm aware of standards of care for all patients including 2 those inmates at jails. 3 Q. Are you aware of any policies and procedures with regard 4 to psychiatric care at Grand Traverse County Jail? 5 A. Community Mental Health has some policies regarding that. 6 Q. Did they have those policies when you were caring for 7 Christopher Morden? 4:35P 8 A. I don't know when those policies were developed or 9 revised. 10 Q. Were you part of developing and/or revising any policies 11 and procedures from CMH? 12 A. No, ma'am. 13 Q. Did you review the policies and/or procedures from CMH 14 with regard to psychiatric care of a patient in jail? 15 A. I believe about six years ago I thumbed through a 16 three-inch manual with all kinds of policies and 17 procedures, but I can't recall that one specifically. 18 Q. When you examined Christopher Morden, was there a nurse in 19 the room? 20 A. On which occasion? 4:36P 21 Q. Any occasion. 22 A. When Mr. Morden was seen on 2-12-02 Student Nurse A. Popa, 23 was present. 24 Q. Was there anybody in the room at any other time when you 25 interacted with Christopher Morden? 136 1 A. Yes. 2 Q. Who? 3 A. On 2-12-02 Tony Karlin, MSW, was present and on 3-12-02 4 Anne Baase from CMH was also present. 5 Q. Any other times anybody was in the room when you examined 6 Christopher Morden? 4:37P 7 A. Typically, I examine the patients in a glassed-in 8 enclosure right under the watchful eyes of the 9 correctional officers so as to always have someone present 10 during my examination. 11 Q. Other than the student nurse you referenced, were there 12 ever any nurses in the room with you when you examined 13 Christopher Morden? 14 A. I do not believe so or it would have been documented. 15 Q. You didn't supervise the nurses, did you? 16 A. No, ma'am. 17 Q. To your knowledge, who supervised the nurses at the jail 18 in your care and treatment of the inmates? 4:39P 19 MR. WIERDA: Objection, foundation. 20 MS. LYNN: I object to foundation. 21 THE WITNESS: I have no knowledge as to the 22 chain of authority at the jail. 23 Q. (MS. TUREK) Did you ever have a meeting with anyone else 24 other than your attorney that included any of the other 25 attorneys in the room? Off the record. 137 1 (Off-the-record discussion.) 2 THE WITNESS: No, ma'am. 3 Q. (MS. TUREK) Did you ever have a meeting with your 4 attorney that included any other people not from his firm? 5 A. No, ma'am. 6 Q. Did you ever talk to Dr. Wilcox about this case, 7 Christopher Morden's case? 4:40P 8 A. I do not believe I did. 9 Q. Did you ever talk to anybody else about Christopher 10 Morden's case? 11 A. I don't believe I discussed this with anybody else with 12 the advice of my attorney. 13 MR. GANO: Upon my advice. 14 THE WITNESS: Upon the advice of my attorney. 15 Q. (MS. TUREK) Do you understand the allegations in the 16 Complaint, in the lawsuit? 17 A. What I understand is that a young man -- 18 MR. GANO: No, she didn't ask you what you 19 understood. She asked if you understood what it is. 20 THE WITNESS: Not really. 21 Q. (MS. TUREK) What did you review for this deposition? 4:41P 22 A. About several hours ago now but about 45 minutes prior to 23 noon, I sat down with my attorney and went through some of 24 these records in his black folder. And prior to this I 25 looked at -- 138 1 MR. GANO: She's not asking you about 2 correspondence between you and me. 3 THE WITNESS: Oh. Well, that's all I looked at. 4 Q. (MS. TUREK) All that is in that pack is the letters from 5 your attorney? 6 A. Uh-huh. 7 Q. The entire thing is letters? 8 A. Uh-huh. 9 Q. No documents attached? 10 A. Nope. 11 Q. Are the only records that you have made with regard to 12 Christopher Morden the records from February 12th, March 13 12th and March 23rd? 4:42P 14 A. Yes, ma'am. 15 Q. And those records are on three consult sheets, is that 16 right? 17 A. And then later transcribed to English. 18 Q. Dictation? 19 A. Yes, ma'am. 20 Q. I notice one of your notes was dictated eight days after 21 Christopher died. 22 MR. GANO: Do you mean the transcription was 23 prepared from the written record eight days after? 24 MS. TUREK: I understand it was dictated. 25 MR. GANO: Why don't you give me which one? 139 1 MS. TUREK: March 23rd. 2 THE WITNESS: It was done on March 23rd. 3 MR. GANO: Can you show us a transcription date? 4 MS. TUREK: You have the original records there. 5 MR. WIERDA: There is no transcribed notes in 6 there. 4:18P 7 Q. (MS. TUREK) Where are the transcribed records? Community 8 Mental Health? 9 A. Yes. I don't have access to those, but the original 10 document was generated on 3-23-02. 11 Q. On 3 what, ma'am? 12 A. 3-23-02. 13 Q. The original document was dictated -- or, beg your 14 pardon -- generated at that point in time? 15 A. Right. 16 Q. At what point in time did you dictate it? 17 A. I don't dictate. They go straight from these. 18 Q. I gotcha. So your handwritten records are 19 contemporaneous -- 20 A. Yes, ma'am. 21 Q. -- with your visit? 22 A. Yes, ma'am. 23 Q. Have you ever destroyed any medical records? 24 A. No, ma'am. 25 Q. Have you ever altered any medical records? 140 1 A. Nope. 2 Q. Have you ever deleted any medical records? 3 A. No, ma'am. 4 Q. Have you have changed any medical records? 5 A. No, ma'am. I don't even have a copy of them. 6 Q. Are you aware of anyone else changing any of Christopher 7 Morden's medical records? 8 A. No, ma'am. 4:44P 9 Q. Are you aware of anyone else destroying any of Christopher 10 Morden's medical records? 11 A. No, ma'am. 12 Q. Do you have a personal relationship with Dr. Wilcox? 13 A. I know him as a colleague, but we have no other contact 14 outside of the office. 15 Q. Other than the CMH medical records and the jail medical 16 records, are there any other records that exist that you 17 authored? 18 A. Not that I know of. 19 Q. Do you believe Christopher is at fault for his death? 20 MR. GANO: I will object to the form of the 21 question. 22 THE WITNESS: I don't know what caused his 23 death; therefore, I can't ascribe blame. 24 Q. (MS. TUREK) Is there a difference between a D.O. 25 psychiatrist and an M.D. psychiatrist? 141 4:45P 1 A. Yes, ma'am. 2 Q. What is that difference? 3 A. It's their initial education. 4 Q. Is the standard of care the same for a D.O. psychiatrist 5 as an M.D. psychiatrist? 6 A. I would hope it would be. 7 Q. Do you know if it is the same? 8 A. I believe that it is. 9 Q. Do you know who Linda Brevitz is? 10 A. Linda Brevitz is a practicing psychiatrist who's the 11 medical director of the child guidance which is under the 12 auspices of Northern Lakes Community Mental Health. 13 Q. Is she is a child psychiatrist? 14 A. Yes, ma'am. 15 Q. She doesn't deal with adults? 16 A. She does deal with adults. 17 Q. I mean not as patients. 18 A. Yes, she does deal with adults as patients. She does 19 child and adults. 20 Q. I gotcha. Did you ask her to be your expert? 21 MR. GANO: I asked her to be her expert. 22 Q. (MS. TUREK) Did you ask her to be your expert? 4:46P 23 A. I asked her to speak to my lawyer. 24 MR. GANO: By the way, I haven't identified her 25 as an expert. She merely filed an affidavit of 142 1 meritorious defense in this case. 2 MS. TUREK: That makes her an expert. 3 MR. GANO: I don't think so. Well, I mean I 4 guess it depends on your definition. I think we have a 5 statute that talks about their status. 6 Q. (MS. TUREK) You were paid by the jail for Christopher 7 Morden's care and treatment? 8 A. No, ma'am. 9 Q. Forgive me. CMH. 10 A. Yes, ma'am. 4:47P 11 Q. So Christopher didn't have to fork over any money, right? 12 A. No, ma'am. 13 Q. Do you believe there was an inherent defect in any drug 14 that was administered to Christopher Morden? 15 A. No, ma'am. 16 Q. Do you believe anyone acted outside the scope of their 17 authority in caring for Christopher Morden? 18 A. Not that I am aware of. 19 Q. We're almost done. In your Answer to the Complaint, we 20 said that Northern Lakes Community Mental health is a 21 corporation, blah, blah, blah. You said that Northern 22 Lakes does not the pertain to you, yet you got into the 23 jail because of Northern Lakes, right? 4:48P 24 MR. GANO: She didn't answer the Complaint. I 25 answered the Complaint. I said the allegations did not 143 1 pertain to this defendant, meaning that the allegations 2 within that paragraph didn't pertain to this defendant, 3 not that Northern Lakes didn't pertain to this defendant. 4 MS. TUREK: Okay. 5 MR. GANO: And I think you're taking that out of 6 context. In fact, I'll amend my pleadings if that's the 7 way you took it. It was merely meant as is typical when 8 you have made an allegation against a co-defendant, 9 there's no need for me to answer that allegation. We have 10 admitted and would admit that we were under contract to 11 the Community Mental Health organization to provide 12 professional services. 13 Q. (MS. TUREK) Doctor, you said that because you don't know 14 what happened to Christopher Morden, you can't blame 15 Christopher Morden for what happened to him? 4:49P 16 A. I can't ascribe blame because I don't know the cause, 17 correct. 18 Q. So you don't have any evidence of voluntary misconduct by 19 Christopher Morden, do you? That caused his death. 20 Forgive me. 4:51P 21 A. Neither for, nor against. 22 Q. Okay. Do you believe that Christopher Morden's ability 23 was impaired because he was under the influence of alcohol 24 or drugs? 25 MR. GANO: Disability when, please? 144 1 MS. LYNN: I'll object to form. 2 Q. (MS. TUREK) At any time during the time period that you 3 were treating him. 4 MS. LYNN: When you say drugs, do you mean drugs 5 not prescribed by any physician? 6 MR. GANO: Yeah, can you break it down? 7 MS. TUREK: Sure. Prescription drugs is one 8 thing, alcohol is another. 9 Q. (MS. TUREK) It's substance dependency or abuse regardless 10 if it's alcohol or drugs, right, Doctor? 11 MR. GANO: I'm sorry. All I want to do is 12 distinguish between prescription -- when you say drugs, 13 you mean prescription medications that he was on and that 14 his ability was impaired as a result of those or illicit 15 drugs and alcohol? 16 MS. TUREK: Both. 4:52P 17 Q. (MS. TUREK) One of your principals at Northern Lakes had 18 said in one of their responses called an Affirmative 19 Defense that Plaintiff's decedent's -- that's Christopher 20 Morden -- ability was impaired under a statute that talks 21 about drugs that impair one's ability to function. Drugs 22 and -- and I'm including alcohol in a drug. Do you do 23 that in your everyday practice, too? 24 MS. DEBLER: Objection to foundation. 25 THE WITNESS: Drugs? 145 1 Q. (MS. TUREK) No. Include alcohol under the heading of 2 drugs. 3 A. Drugs and alcohol are considered. When we have a positive 4 response, we sort it out. 5 Q. Okay. Do you believe Christopher's ability was impaired 6 because of drugs and/or alcohol during the time period 7 that you were treating him? 4:53P 8 MR. WIERDA: Objection, form and foundation. 9 MS. LYNN: Same objection. 10 MR. GANO: I join. 11 THE WITNESS: He had an impairment in judgment. 12 The question of etiology, whether it's medication induced 13 or mental illness induced, would eventually clear itself. 14 It's my belief that inmates supervised by the jail do not 15 readily have access to alcohol. 4:54P 16 I also believe that the correctional officers do 17 what they can to keep illicit and recreational drugs out 18 of the jail, but I do know that on occasion they find 19 their way in. So in response to your question, I do 20 believe that he had impaired judgment, etiology unknown. 21 Q. (MS. TUREK) Do you have any evidence that Christopher was 22 using any type of illicit drug while he was -- 23 A. No. 24 Q. Okay. Thank you. If I may look at the original medical 25 records real quick and then I think we'll be done. 146 1 MS. LYNN: I have a few questions before we 2 close the record. Just a few. I promise not four or five 3 hours, just a few. 4:55P 4 MS. TUREK: Whenever you're ready, go ahead. I 5 can listen. 6 MS. LYNN: Do you want me to go ahead at this 7 point? 8 MS. TUREK: Yes. Sure. 9 EXAMINATION 10 BY MS. LYNN: 11 Q. Dr. Conlon, my name is Eleanor Lynn. I represent Dr. 12 Wilcox. You know Dr. Wilcox, right? 13 A. Yes, ma'am, I do. 14 Q. It sounds like you have known him and worked with him for 15 several years? 16 A. Yes, ma'am, I have. 17 Q. And Christopher Morden is not the only case that you have 18 worked with Dr. Wilcox on in which the inmate was a 19 patient who was also on psychotropic medication, is that 20 fair? 21 A. That's correct. 22 Q. In fact, in your experience working with Dr. Wilcox, is it 23 your impression if an inmate comes in who's on 24 psychotropic medications, Dr. Wilcox will call you in on 25 the case to work with the inmate and work with him in 147 1 treating the patient? 2 A. That's correct. 3 Q. Do you know of any case where Dr. Wilcox has ever treated 4 a patient who's an inmate in the jail who's on 5 psychotropic medications without the assistance of a 6 psychiatrist? 4:56P 7 A. I would believe that Dr. Wilcox, as any family 8 practitioner, would feel comfortable working with some 9 medications and other medications would require the 10 assistance of a psychiatrist. Dr. Wilcox has proven that 11 in the past, that if he feels he's not familiar with this 12 medicine, he's going to get appropriate assistance. 13 Q. And you are a board certified psychiatrist? 14 A. Yes, ma'am. 15 Q. And also board certified in -- I'm sorry. Help me out. 16 A. Forensics. 17 Q. That's not the one I'm thinking about. The one you just 18 got. 19 A. Oh. Clinical psychopharmacology. 20 Q. Thank you. Clinical psychopharmacology. And you know 21 that Dr. Wilcox is family practitioner, correct? 22 A. Yes, ma'am. 23 Q. And you as a psychiatrist have a lot of experience with 24 prescribing and working with patients, treating patients 25 who are on antipsychotic or psychotropic medications, 148 1 correct? 4:58P 2 A. I have a lot of experience with that, yes. 3 Q. And you would understand as a psychiatrist who has that 4 experience that you have no more expertise in that area 5 certainly than the average family practitioner, correct? 6 A. That's true. 7 Q. And when you made certain recommendations in this case, 8 you made those with the understanding that Dr. Wilcox 9 would almost certainly accept those recommendations, is 10 that fair? 11 A. Any consultant hopes that the requesting physician will 12 take their advice and act accordingly. 13 Q. And that likely he would defer to your expertise as a 14 psychiatrist? 15 A. Yes. 16 Q. And has that been your experience with Dr. Wilcox, that he 17 has deferred to your expertise as a psychiatrist in the 18 prescription and management of psychotropic medications in 19 general? 20 A. The vast majority of the time Dr. Wilcox has taken my 21 recommendations. 22 Q. And have there been times when he has countermanded your 23 recommendations? 4:59P 24 A. In the many years that Dr. Wilcox and I have worked 25 together, there have been some times when he has decided 149 1 to pursue another course of action. 2 Q. In this particular case as far as you can tell, did he 3 follow your recommendations? 4 A. Yes, ma'am. 5 Q. All right. And there was one particular time when on the 6 23rd of March you saw Mr. Morden again and you talked 7 about that visit earlier in your testimony, do you 8 remember that? 9 A. Yes, ma'am. 10 Q. First, let me ask you this. Would you normally under 11 circumstances present in this case see the inmate 12 approximately once a month, a patient like Mr. Morden? 13 MS. TUREK: Objection, form and foundation. 14 Q. (MS. LYNN) Assuming if there are no special complications 15 or if you're not alerted to any particular thing. I mean 16 I notice you saw him on the 12th of February and then you 17 saw him on the 12th of March. Is that because of the 18 cycle one-month routine. 5:00P 19 MS. TUREK: Same objection. Asked and answered. 20 THE WITNESS: Whenever you make a medication 21 change, you want to know that it was effective, so you ask 22 the attending to consider allowing you to re-see the 23 patient which Dr. Wilcox has always graciously agreed to. 24 Q. (MS. LYNN) All right. So you recommended follow-up in 25 one month and that's what occurred? 150 1 A. Yes, ma'am. 2 Q. When you saw him on the 12th of March, I think you 3 recommended follow-up in one month, if I remember right? 4 I can double-check that. Yes. I think it says return to 5 general population. Would review plus or minus one month 6 or PRN. Right? 7 A. Right. 8 Q. Then when you saw him on the 23rd of March, of course, 9 that was less than the one month and do you understand 10 that you saw him because you were asked to see him at that 11 time? 5:01P 12 A. Yes. I cannot tell you who asked me to see him, but that 13 would be why I would see him prior. That's as needed. 14 Q. And you commented on the fact that although you saw him on 15 the 23rd, the medication change was not made until the 16 25th. 17 A. Which would be Dr. Wilcox's normal day back to the jail. 18 It makes sense, yes. 19 Q. Okay. Well, my question actually was going to be do you 20 know whether March 23, 2002 was a Saturday? 21 A. I have no idea. 22 Q. Okay. And when you made your recommendations on March 23 23rd for the change in medications, you didn't make those 24 recommendations as a stat order, did you? 25 A. No, ma'am. 151 1 Q. And you didn't notify anybody at that time that you wanted 2 them implemented immediately, did you? 3 A. No. The usual procedures should be followed. 5:02P 4 Q. All right. And you didn't make any requests for obtaining 5 any lab work on Mr. Morden such as a CPK or a myoglobin, 6 correct? 7 A. No, ma'am. 8 Q. If you thought those were indicated, could you have made 9 those recommendations? 10 A. Yes, ma'am, and I would have gone the extra step and 11 contacted either the sergeant who you can always go to in 12 an emergency or as I noticed I didn't see him with the CMH 13 person, I would have gone with the sergeant of the day. 14 Or if a CMH worker is with me and I need something 15 urgently, then I would inform that CMH person who would 16 make it happen. So clearly there is no urgency in this 17 note. 18 Q. In your private practice when you have patients who are on 19 antipsychotic medications such as Risperdal or Seroquel, 20 how often do you generally see them in your office? 5:03P 21 A. My private practice is mostly psychotherapy. I have maybe 22 four or five med management only patients, but the rest of 23 them I see for psychotherapy so I see them on a much more 24 frequent basis. Some of them are on medicines. The few 25 people I see for med management only, none of them are on 152 1 antipsychotic medications. 2 Q. All right. Let me ask you this hypothetically. In your 3 private practice if you have a patient who's on those 4 psychotropic or antipsychotic medications and it's a med 5 management patient only, what would the standard of care 6 require with regard to how often you see then in the 7 office to monitor the effects of the medication? 8 A. Typically, I make sure they have a follow-up appointment 9 in three or four weeks. They are given several numbers to 10 contact me if they have something they consider to be an 11 unusual event. The hospital operator has instructions to 12 put through a patient who calls for me who identifies 13 themselves as my private patient so that I would be 14 available 24/7. If I am in fact out of town, I have 15 someone else covering my practice to take those phone 16 calls. 5:04P 17 Q. Just as a routine matter, though, the vital signs are not 18 taken every day, for example, would that be correct? 19 A. That would be very correct. 20 Q. Okay. 21 MS. LYNN: Thank you. 22 RE-EXAMINATION 23 BY MS. TUREK: 24 Q. Doctor, how about once a month vital signs? 25 A. In my private practice? 153 1 MS. LYNN: What's the question? 2 Q. (MS. TUREK) Do you take vital signs once a month? 3 A. If my patient has no primary care doctor who's monitoring 4 their medical condition, I do what I can to make sure 5 they're stable such as taking a blood pressure and taking 6 a pulse. And given this day and age, I try to get a 7 weight. 5:05P 8 Q. On March 23, 2002 you hand wrote improvement noted on 9 Risperdal but in this patient likely causing orthostatic 10 hypotension. Do you remember that? 11 A. Yes. 12 Q. Do you have it in front of you? 13 A. Yes. 14 Q. Great. Why did you suggest switching to a different 15 neuroleptic? 16 A. If it appeared as though Risperdal were causing 17 orthostatic hypotension, I should switch to another 18 medicine that would not cause that side effect. 19 Q. And that side effect again could be part of NMS, right? 5:06P 20 MR. GANO: Asked and answered multiple times 21 certainly. 22 THE WITNESS: Yes. 23 MS. TUREK: Thank you, Doctor. 24 MS. DEBLER: Are you done? 25 MS. TUREK: No. 154 1 Q. (MS. TUREK) Doctor, Munson Medical Center ran a bunch of 2 labs the day that Christopher showed up there in an 3 cardiopulmonary arrest situation. 4 A. Uh-huh. 5 Q. Did you have the opportunity to review any of those lab 6 results? 7 A. No, ma'am. 8 Q. Thank you, Doctor. 9 A. Thank you. 10 MR. WIERDA: I don't have any questions. 11 EXAMINATION 12 BY MS. DEBLER: 13 Q. I have just a couple more questions and I'll be done, Dr. 14 Conlon. I represent Northern Lakes Community Mental 15 Health Authority and Great Lakes Community Mental Health. 16 And during the questioning by Ms. Turek, plaintiff's 17 counsel, you were asked a few questions and I just want to 18 ask you some more questions by way of clarification. 7:28A 19 A. Uh-huh. 20 Q. Terms we use like agent and principal so I want you to 21 clarify that. You signed a contract, did you not, for 22 physician services with Great Lakes Community Mental 23 Health? 24 A. Yes, ma'am. 25 Q. Is it your understanding the nature of your relationship 155 1 to Great Lakes Community Mental Health was one of an 2 independent contractor? 3 A. Yes, ma'am. 4 Q. Is it also your understanding based on your reading of the 5 contract or your understanding of the contract generally 6 that Great Lakes Community Mental Health was not to 7 interfere in any way of your exercise of control and 8 discretion over the manner and method of furnishing your 9 professional services? 10 A. The honest answer is that I haven't read that contract in 11 eight years and if you say it's in there, I will believe 12 you. 13 Q. Thank you. 14 MS. DEBLER: No further questions. 15 RE-EXAMINATION 16 BY MS. TUREK: 17 Q. You wouldn't have seen Christopher Morden but for 18 Community Mental Heal, right? 5:08P 19 A. Correct. 20 Q. Thank you. 21 MS. LYNN: Just two more questions. 22 RE-EXAMINATION 23 BY MS. LYNN: 24 Q. Doctor, a patient can have extrapyramidal symptoms from 25 neuroleptic medications without necessarily having 156 1 neuroleptic malignant syndrome, true? 2 A. Absolutely true. 3 Q. And is it fairly common or at least not uncommon for you 4 to see side effects including extrapyramidal symptoms from 5 neuroleptic medications? 6 A. It's extremely common. 7 Q. Thank you. 8 MS. LYNN: Nothing further. 9 RE-EXAMINATION 10 BY MS. TUREK: 11 Q. If the primary care physician believes that the patient is 12 being overmedicated and that's communicated to you, what 13 would be your response in this setting? Let's say, after 14 March 23rd, Dr. Wilcox believed that the patient was being 15 overmedicated. 16 A. I would reevaluate the patient if that's likely what 17 happened. 18 Q. If what happened? 19 A. I said that's likely what happened, although I don't know. 20 That's likely what happened as I saw him two weeks instead 21 of a month. 5:09P 22 Q. You didn't see Christopher Morden after March 23rd, right? 23 A. No, ma'am. 24 Q. Dr. Wilcox wrote in the medical record that he thought the 25 patient was being overmedicated on March 25th. 157 1 A. Okay. 2 Q. And if Dr. Wilcox thought the patient was being 3 overmedicated for whatever reason, you would have 4 re-evaluated the patient, you said, right? 5 A. Yes, ma'am. 6 Q. What would have been included in your reevaluation of the 7 patient? 8 A. I would take a history, ask some cognitive questions, 9 listen to his speech pattern, look at his attention, see 10 how alert he was, make an assessment for ability to 11 interact. I would also check with peripheral resources as 12 I often do, review any materials that were presented to me 13 including correctional officer's notes, and then make an 14 assessment. And that would eventually find its way to Dr. 15 Wilcox. 16 Q. Thank you, Doctor. One more. Sorry. Were these medical 17 records by Dr. Wilcox, the nurses -- I think it's just Dr. 18 Wilcox and the nurses, were these provided to you at each 19 of your visits? 5:10P 20 A. No, ma'am. 21 Q. You never had access to these medical records? 22 A. If I wanted them, I could have access, but I have never 23 asked for them and consequently have never been given 24 them. 5:11P 25 Q. So even if there were vital signs on here, you wouldn't 158 1 know what those vital signs were, right? 2 A. That's correct. 3 Q. You would agree that standard of care for a psychiatrist 4 requires inquiring into vital signs? 5 MR. GANO: Don't answer that. It's asked and 6 answer multiple times before. 7 MS. TUREK: No, that one wasn't. And there's no 8 privilege. Go ahead, Doctor. 9 MR. GANO: No. I'm not asserting it as a 10 privilege. I'm saying -- 11 MS. TUREK: That's the only time you can tell 12 her not to answer. 13 MR. GANO: Not five hours into the deposition 14 we're going over the same thing. 15 MS. TUREK: We were here eight hours yesterday. 16 Don't even go there. Go ahead, Doctor, that's your last 17 question. 18 MR. GANO: No. You don't listen to her. You 19 listen to me. 20 MS. TUREK: We were here for eight hours 21 yesterday. It's a simple question. You don't have to 22 grandstand. Just a simple question. 23 MR. GANO: Give it to me again. 24 MS. TUREK: Go ahead, Reatha, if you would. 25 That's all. Just one question that was not asked and 159 1 answered. 5:12P 2 (Record read as follows: 3 8 Q. So even if there were vital signs on 4 here you wouldn't know what those vital 5 signs were, right? 6 A. That's correct. 7 9 Q. You would agree that standard of care 8 for a psychiatrist requires inquiring 9 into vital signs?) 10 THE WITNESS: I stand by my previous answer that 11 I rely on charting by exception. If there is anything 12 exceptional, that I would be notified of that. 13 Q. (MS. TUREK) How can you rely on charting by exception if 14 you haven't even seen the medical record? 15 A. That I would be notified if there was an exception. 16 Q. All right, thank you. 17 MS. TUREK: And thank you, Mr. Gano. 18 MS. LYNN: Just a couple questions to follow-up. 19 I'm sorry. 20 RE-EXAMINATION 21 BY MS. LYNN: 22 Q. You were asked about this notation by Dr. Wilcox regarding 23 whether the patient was overmedicated and whether you saw 24 the patient after that. And do you understand that 25 notation was made on 3-2-02 which is one day after you 160 1 had -- one day after the plan was implemented for the 2 change to Seroquel that you had recommended? Do you 3 understand that? 5:13P 4 A. Previously I have not reviewed that. I see that now. 5 Q. Okay. And then Dr. Wilcox also documented continue with 6 plan to change to Seroquel and he noted that he had 7 reviewed the CMH consult or rechecked CMH consult, 8 reviewed. So with that in mind, would you have done 9 anything differently at that point if you were told that 10 it's one day after the change of medications and that you 11 had already changed the medications to Seroquel when Dr. 12 Wilcox documented his observations? 5:14P 13 A. What are you asking me? 14 Q. Do you understand my question? 15 A. No, ma'am. 16 Q. Okay. You were asked about that whole scenario. I'm 17 saying if you understand that Dr. Wilcox made those 18 observations and documented that within one day of the 19 change in medication that you had recommended. First of 20 all, would you necessarily expect Mr. Morden to be showing 21 much improvement yet, you know, less than 24 hours later? 22 MS. TUREK: Objection, form and foundation. 23 Q. (MS. LYNN) And if you were told at that point that Dr. 24 Wilcox had made those observations, but his plan was to 25 continue with your recommendations to change to Seroquel, 161 1 would you have necessarily made any changes? 2 A. No. It's too premature to see anything. He may be 3 sedated with a change in medicine, but I wouldn't jump at 4 that. 5 Q. Okay. Thanks. 6 A. He's in a controlled setting and monitored. 7 Q. Okay. Thanks. 8 MS. LYNN: Nothing further. 9 MS. DEBLER: Nothing further. 10 MS. TUREK: Are we done? 5:17P 11 MR. GANO: Yes. 12 (Deposition ended at 5:20 p.m.) 13 14 15 16 17 18 19 20 21 22 23 24 25 162 1 CERTIFICATE OF NOTARY PUBLIC 2 3 (STATE OF MICHIGAN ) DEPONENT: DR. MARILYN CONLON 4 ( SS ) RECORDED: JUNE 7, 2005 (COUNTY OF KALKASKA) LOCATION: TRAVERSE CITY, MICHIGAN 5 6 Being a Notary Public commissioned and qualified in and for the State of Michigan at Large, I do hereby certify 7 that pursuant to notice there came before me the deponent herein, who was by me first duly sworn to testify to the truth 8 and nothing but the truth touching and concerning the matters in controversy in this cause. 9 Being thereupon carefully examined under oath, 10 said examination was recorded stenographically, and Was later reduced to transcription under my supervision; said 11 transcription being a true record of the testimony given by the witness. 12 I further certify that I am neither attorney or 13 counsel for, nor related to or employed by any of the parties to the action in which this deposition was taken; and, 14 further, that I am not a relative or employee of any attorney for counsel employed by the parties hereto, or financially 15 interested in the action. 16 IN WITNESS WHEREOF, I have hereunto subscribed my signature this 22nd day of June, 2005. 17 18 19 20 __________________________________________ Reatha M. Cochran, 21 Certified Shorthand Reporter, CSR-2427 Registered Professional Reporter, RPR-2750