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1 (Proceedings recommenced at 9:04 a.m.,

2 May 15, 1997, with the court, counsel and defendant

3 present.)

4 COURT: Good morning. Are we ready to go?

5 Mr. Wadding?

6 MR. WADDING: Yes.

7 COURT: Mr. Correll?

8 MR. CORRELL: Yes, Your Honor.

9 COURT: Mr. Wadding?

10 MR. WADDING: Thank you. Call Dr. Miller to

11 the stand.

12 GEOFFREY MILLER, M.D.,

13 called as a witness on behalf of the state, being first

14 duly sworn by the court, was examined and testified as

15 follows:

16 COURT: Mr. Wadding?

17 MR. WADDING: Thank you, Your Honor.

18 DIRECT EXAMINATION

19 BY MR. WADDING:

20 Q. Would you state your full name and spell your

21 last name the record, please.

22 A. Geoffrey Miller. Actually the first name is

23 spelled G-E-O-F-F-R-E-Y. Miller is M-I-L-L-E-R.

24 Q. And your occupation, sir?

25 A. I'm an emergency physician.

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1 Q. And how long have you been an emergency room

2 physician?

3 A. About two and a half years.

4 Q. And where are you employed?

5 A. Covenant Hospital.

6 Q. And could you describe your training and

7 education in achieving that position as an emergency room

8 physician?

9 A. I originally trained in family practice and

10 was in a rural practice in Anamosa, Iowa, but made a

11 career change, subsequently went back and took simple

12 continuing education courses and went on and became board

13 certified in emergency medicine and then obtained the job

14 at Covenant. At Anamosa I worked in emergency rooms most

15 of the 13 years I was there off and on.

16 Q. And where did you receive your education?

17 A. Oh, I was -- University of Iowa Med School.

18 The residency was in Cedar Rapids.

19 Q. And are you a licensed doctor in the state of

20 Iowa?

21 A. Yes.

22 Q. How long have you held your license in the

23 state of Iowa?

24 A. Since 1980.

25 Q. And could you briefly describe generally what

445

1 your duties are as an emergency room physician?

2 A. Well, we are at the hospital, and basically

3 at the emergency room just -- we take all-comers, so we

4 take major traumas all the way down to the common cold.

5 We are there to do initial assessments, initial

6 stabilization, make decisions about whether people should

7 be admitted or sent home or whether they need to be

8 transferred to a larger facility.

9 Q. Now, were you working in your position as an

10 emergency room physician on October 4th, 1996?

11 A. Yes.

12 Q. And did you receive and assess or treat an

13 individual by the name of Tamara Kleinheksel?

14 A. Yes, I did. But actually I think it was on

15 10-5 at 1 in the morning when I first met her.

16 Q. Okay. And do you recall -- can you describe

17 how you first met her then?

18 A. Tamara had been -- had been in a motor

19 vehicle accident and had originally gone to Sartori

20 Hospital who had contacted a neurologist, Dr. Choi, who

21 accepted her and was transferred to Covenant Hospital.

22 She was very briefly stabilized in Sartori. Dr. Choi

23 asked me to see her also to continue her stabilization

24 when she arrived at our hospital.

25 Q. And did you do that?

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1 A. Yes.

2 Q. And could you describe what -- what you

3 observed, or what you observed of Ms. Kleinheksel's

4 condition?

5 A. Well, she was obviously seriously injured.

6 She had, in the motor vehicle accident, reported that she

7 was in the back seat unrestrained. When she arrived at

8 Sartori, she had been in a coma. They had done a CAT

9 scan. That was the reason they were transferring her.

10 The -- when en route to our facility, she started to have

11 seizures. She was having rhythmic deviation of her eyes,

12 I don't remember which side, but to one side. She was

13 completely in coma. She had a laceration to her chin.

14 And that was kind of the state that she arrived in.

15 Q. And what kind of an assessment did you make

16 of her condition then after she arrived?

17 A. Well, our first duty, as we worry about, we

18 worry about making sure that her airway is adequate, make

19 sure her breathing is adequate and then make sure her

20 circulation is adequate, and those were stable. So then

21 we move on to what we call secondary assessment, which is

22 basically a head-to-toe exam. And the main findings

23 were, you know, basically what I elicited, she had the

24 seizure going on with the eyes deviating. She had the

25 laceration to her chin. Her lungs, chest, abdomen, all

447

1 seemed to be fairly good on exam. The -- we then

2 proceeded to do several things to try and stabilize the

3 situation.

4 Q. When you said that you stabilized her

5 breathing, what are you -- what did you do to do that?

6 A. Well, we -- we did end up intubating, which

7 is passing a plastic tube down into her trachea and then

8 breathing for her, but that wasn't as much to stabilize

9 her breathing as it was to control her intracranial

10 pressure. One of the problems you have in a significant

11 head injury such as this where you do have definite

12 swelling is the intracranial pressure rises, and that

13 does further damage, so one of the -- in fact, the

14 fastest way we have of bringing that down is to

15 hyperventilate a patient, in other words, to increase

16 their breathing rate and lower their carbon dioxide.

17 When you have a deteriorating head injury, one of the

18 steps we take is to hyperventilate the patient.

19 Q. Is that how you would characterize Ms.

20 Kleinheksel, as a deteriorating head injury?

21 A. At that point she was.

22 Q. And did she stand a substantial risk of death

23 at the -- from the injuries that you observed?

24 A. I felt that she was at a substantial risk.

25 In fact, the Father stopped in and did last rites.

448

1 Q. And do you think that that risk was a -- that

2 risk was a result of the head injury that you described?

3 A. Yes.

4 Q. And were the injuries that you observed in

5 the emergency room consistent with injuries of a person

6 in an automobile accident?

7 A. It certainly is a reasonable explanation for

8 the injuries.

9 Q. And what further treatment or what further

10 action was taken with Ms. Kleinheksel?

11 A. Well, in addition to the intubation, as we

12 described, we also were attempting to control her

13 seizures. We gave her medication to stop the seizures,

14 initially some Ativan and Versed, subsequently gave her

15 Dilantin, another anti-seizure medication that we

16 commonly use in head injuries. Of course, when we had

17 her intubated, we continued to breathe for her because we

18 had medically paralyzed her at that point. We maintained

19 I.V. fluids. We -- typically in head injuries you don't

20 give full-blown I.V. fluids if they have adequate blood

21 pressure. We limit the amount of fluids we give them so

22 we do not increase the pressure inside the brain.

23 Q. And did you then -- was she admitted to

24 Covenant Hospital?

25 A. No, she was not. The decision, after Dr.

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1 Choi, the neurologist, saw her, he also talked to Dr.

2 Chung, who is the neurosurgeon, and after discussion,

3 they felt that she would be better managed at the

4 University of Iowa Hospitals.

5 Q. And was she then transported?

6 (At 9:15 a.m., May 15, 1997, a recess was

7 taken, and Scott Halverson, Certified Shorthand Reporter,

8 reported the remaining non-jury trial proceedings held

9 May 15, 1997.)

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451

1 THE COURT: You may remain seated. You are still

2 under oath and please give your full name to the reporter

3 THE WITNESS: Geoffrey Miller.

4 THE COURT: Mr. Wadding.

5 MR. WADDING: Thank you, your Honor.

6 GEOFFREY MILLER,

7 DIRECT EXAMINATION (cont'd.)

8 BY MR. WADDING:

9 Q. Dr. Miller, I believe that I was discussing with

10 you Miss Kleinheksel. What was the end result of your

11 contact with her at the at the emergency room at Covenant

12 Medical Center?

13 A. Yes, we had discussed the case with Dr. Choi,

14 C-H-O-I, a neurologist, and then he had discussed the case

15 with the Dr. Chung, and the decision was made to transfer

16 her to the University of Iowa to the neurosurgeons at Iowa

17 City.

18 Q. And was that then done?

19 A. Yes.

20 Q. And did you have any further involvement with

21 Miss Kleinheksel?

22 A. No.

23 MR. WADDING: That's all the questions. I have thank

24 you.

25 THE COURT: Mr. Correll.

452

1 MR. CORRELL: Thank you.

2 CROSS-EXAMINATION

3 BY MR. CORRELL:

4 Q. Doctor, do you have your reports available to

5 you?

6 A. I have my typewritten notes.

7 Q. Does that note -- or do you employed independent

8 recollection as to what time Miss Kleinheksel was received

9 at Covenant?

10 A. This note doesn't state so. I was reviewing the

11 medical record yesterday. I think she came in about 1:02.

12 Q. And is it your understanding that she had been at

13 Sartori Hospital prior to coming to Covenant?

14 A. Yes.

15 Q. Did you ever review the Covenant medical records

16 regarding her?

17 A. The Covenant medical records, yes.

18 Q. Excuse me, the Sartori records?

19 A. No.

20 Q. Would she have been -- do you have any

21 understanding of approximately how long she would have

22 been at Sartori Hospital?

23 A. No.

24 Q. In the year -- I guess the two and a half years

25 that you have been at Covenant in the emergency room would

453

1 you say that it is not uncommon for hospitals in this area

2 to refer people to the Covenant emergency room?

3 A. Not uncommon.

4 Q. And isn't that because Covenant emergency room

5 has a very good staff and very good machinery and all the

6 services that are needed to treat people in an emergency

7 care situation?

8 A. Being larger we have more equipment, yes.

9 Q. And you treat more people --

10 A. Yes.

11 Q. -- because of that, don't you?

12 A. Um-hum.

13 Q. And wouldn't it be fair to say that in the past

14 you have had, in fact, referrals from Sartori Hospital to

15 the Covenant emergency room?

16 A. Yes.

17 Q. And the fact that a person would be referred from

18 Sartori or a similar smaller type hospital to Covenant,

19 that would be basically indicative that the referring

20 hospital or physicians would be of the opinion that you

21 could offer services that they were unable to provide;

22 wouldn't that --

23 MR. WADDING: I'm going on object that to that, your

24 Honor. The question is actually testimony and it's not

25 relevant. It's not within the scope of the direct

454

1 examination and would -- and I think that's all the bases

2 I have.

3 THE COURT: The objection is overruled. You may

4 answer.

5 MR. CORRELL: Excuse me, I never did get to finish my

6 question. I don't know if the witness understood my

7 question or if it should be read back. I was going to ask

8 that you read it back.

9 THE COURT: If you hadn't finished, do you want to

10 finish your question or do you know whether you finished

11 your question?

12 MR. CORRELL: I know I didn't finish my question. I

13 was up to the last word. I'll leave it up to the Court or

14 the witness if I should rephrase it or have the reporter

15 read it back.

16 THE COURT: Why don't you just ask him again if you

17 weren't finished.

18 MR. CORRELL: Okay. Thank you, your Honor.

19 BY MR. CORRELL:

20 Q. Isn't it fair to say, based on your experience,

21 that when you have received transfers or referrals from

22 other hospitals in this area, including Sartori, that is

23 because they have a belief that you have services or

24 equipment that are unavailable to them?

25 A. Yes.

455

1 Q. There never was any indication that there was a

2 request to transfer Miss Farrell to your hospital; isn't

3 that a fair statement.

4 MR. WADDING: I'm going to object, your Honor. It's

5 outside the scope.

6 THE COURT: Overruled.

7 THE WITNESS: Could you repeat that again.

8 BY MR. CORRELL:

9 Q. You have no knowledge of any request from Sartori

10 or any physicians at Sartori to refer Juli Farrell to

11 Covenant Hospital. Am I not correct on that?

12 A. I don't have any knowledge of Juli Farrell.

13 Q. Would it be fair to say that from your experience

14 the people that are referred to Covenant from other

15 emergency rooms are generally more, or are considered to

16 be the more seriously injured people?

17 A. This is true.

18 Q. And isn't it fair to say, sir, that one of the

19 strengths of Covenant is you are trained and very aware of

20 when some other hospital can do something that even you

21 can't do?

22 A. You like to think that you are aware of which

23 hospital is better. I mean, such as the case that she

24 was transferred to the University of Iowa because we felt

25 that they could care for her better than we.

456

1 Q. That is the goal of medical services to get the

2 patient to a facility that is best able to meet the needs

3 of that patient; isn't that a fact, sir?

4 A. Yes.

5 Q. And Miss Kleinheksel was only at Sartori or at

6 Covenant for how long a period of time?

7 A. I think between about two or three hours.

8 Q. And within that period of time you were able to

9 determine that she would be better served -- in spite of

10 your valiant efforts she would be better served by being

11 transferred to another hospital; is that a fair statement,

12 sir?

13 A. That's what we felt, yes.

14 Q. And during that period of time you were in

15 consultation with at least two other specialists?

16 A. Yes.

17 Q. And she was then transferred to the University

18 Hospitals in the early morning hours of October 5, 1996,

19 is that not a fact?

20 A. Yes.

21 Q. And she was treated down there for a period of

22 time, is that a fair statement?

23 A. I actually don't know much beyond after she left

24 Covenant.

25 Q. Would you say that as you sit here today that you

457

1 are well pleased and well satisfied with the decision to

2 refer her from Covenant on down to University of Iowa

3 Hospitals?

4 A. I think it was the right decision at the time.

5 Q. Okay. It was the right decision at the time and

6 it was the right decision as you sit here today, isn't it?

7 A. Yeah.

8 Q. And would you agree that she and her family are

9 fortunate that referral was made?

10 MR. WADDING: I'm going to object, your Honor. It's

11 an opinion that has no relevance to this incident. I

12 mean, the whole point of Mr. Miller's testimony is to

13 prove an injury. It's not whether we believe that they

14 had done the right thing or not. It's just not relevant.

15 THE COURT: Overruled.

16 THE WITNESS: Yes.

17 BY MR. CORRELL:

18 Q. And you have not followed her case since her

19 transfer to the University Hospitals, is that correct?

20 A. No, in fact, about the last direct feedback

21 was -- we often hear from the university a couple days

22 later how somebody is doing, and we did hear basically she

23 is still alive but I believe she was still in a coma at

24 that point. I understand that she has recovered some now

25 since then.

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1 MR. CORRELL: Thank you, that's all I have.

2 MR. WADDING: Mr. Wadding.

3 THE COURT: Thank you.

updated 08/01/10