William L. England, Jr., Administrative Law Judge
Good morning. Today's date is March 19, 2001. My name is William L. England, Jr. That's E-N-G-L-A-N-D. And I am an Administrative Law Judge with the Office of Administrative Hearings, a separate and independent agency of Administrative Law Judges organized under the Executive Department of Maryland State Government.
Today's hearing is being convened at the University Hospital which is located in Baltimore, Maryland and it is an Involuntary Admissions hearing on behalf of Ms. Nancy Moran.
Let the record reflect that Ms. Moran is present in the hearing room and is represented by counsel, Linda Gordon, Esquire, of the Public Defenders Office and the Hospital's representative is Mr. Thomas Lanz.
In an Involuntary Admissions hearing the standard of proof is by clear and convincing evidence and the burden of proof rests with the Hospital.
Are there any preliminary matters?
Linda Gordon, Esquire, Public Defender
No.
William L. England, Jr., Administrative Law Judge
Will all individuals who are going to testify raise your right hands to be sworn in.
Do you solemnly swear or affirm on the penalty of perjury that the testimony you give is the truth, the whole truth and nothing but the truth?
[Voices]
I do. I do. I do.
William L. England, Jr., Administrative Law Judge
Thank you. Let the record reflect that the four individuals raised their right hands and answered in the affirmative.
Mr. Lanz, since the burden of proof rests with the Hospital, you may call your first witness.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K., your Honor, my first witness will be Dr. Mullen. However, before I move on to that I would like to read the legal paperwork for today's hearing.
Starting with the Emergency Petition Evaluation, 3/8/01 by Dr. Ossip on Ms. Moran, it states "evaluee is demonstrating the following behavior that leads me to conclude that she is presently suffering from a mental disorder. Patient is manic, disorganized, paranoid, labile, agitated and not compliant with medications. There is clear and imminent danger of the evaluee doing harm to self or others because the patient is psychotic, demonstrating very poor judgment by disrobing, leaving front door open, walking the streets at night alone, and agitated.
Ms. Moran was then seen at University of Maryland's Emergency Room where an application for Involuntary Admission was completed by Dr. Ece Tek on 3/8/01 and then two certificates accompany those starting with one by Dr. Worodi, the second by Dr. Baldomerreo. Both physicians have indicated that they're licensed to practice medicine and indicated diagnosis of bipolar disorder, manic with psychotic features toward Ms. Moran.
The six question report was completed by Dr. Baldomerreo on 3/8/01 also and I'll read that now.
History including mental status: Patient is a 46-year-old white female with history of bipolar disease. Now presents with paranoid and grandiose delusions. Impaired reality testing. Disorganized thought process. She has been emergency petitioned by her outpatient psychiatrist for continuing diagnosis of bipolar disorder, currently manic.
Criterion #2: Patient's insight and judgment are very poor. Reality testing is extremely impaired. She is a potential danger to herself.
Criterion #3: Patient has paranoid delusions. Believes people are after her and trying to hurt her.
Criterion #4: Patient's insight is very poor. She does not believe she has a psychiatric disease.
Criterion #5: Patient is not able to understand simple tasks. She appears to be responding to internal stimuli. She is unpredictable and needs structured environment and restart her medication.
There is a Notice of Hearing. There is also a Notice of Rights in the chart and your honor, for the record, Ms. Moran's hearing was postponed last week.
William L. England, Jr., Administrative Law Judge
All right. Any questions for the record?
Linda Gordon, Esquire, Public Defender
Yes. The Notice of Hearing. Is it signed by a Facility Representative?
Thomas Lanz, Esquire, Attorney for the Hospital
Uh. Facility Representative is left blank.
Linda Gordon, Esquire, Public Defender
So there is no indication who was the person that filled this form out.
Thomas Lanz, Esquire, Attorney for the Hospital
I don't see any notification on this form of who filled this form out. If that is the question.
Linda Gordon, Esquire, Public Defender
O.K. And the psychiatrist - did she fill out the second page where it certifies that all the above, is true, correct, etc. There's a second page of the Emergency Petition.
Thomas Lanz, Esquire, Attorney for the Hospital
The second page is signed and dated by Dr. Ossip.
Linda Gordon, Esquire, Public Defender
May I see that, please?
[pause]
O.K., it looks like the doctor signed it but she didn't fill in anything. She didn't fill in the patient's name or who was going to transfer her the patient to the Hospital or which hospital the patient was going to go to.
Nancy Moran, Patient
May I interrupt at this point, she had a discussion ...
Linda Gordon, Esquire, Public Defender
When it is your turn to testify, I'll let you know.
Nancy Moran, Patient
I just wanted to bring it to the judge's attention, O.K.?
[pause]
William L. England, Jr., Administrative Law Judge
I note - that I mean - are you alleging that this doesn't meet the statutory?
Linda Gordon, Esquire, Public Defender
I'm just saying that it's not complete. Fully. That she - the doctor - apparently attached it but didn't fill in the patient's name or which hospital the patient should be transported to.
William L. England, Jr., Administrative Law Judge
I understand your point, there, but I guess my question is - do you have any reason to think that this is not the doctor that actually --
Linda Gordon, Esquire, Public Defender
No.
William L. England, Jr., Administrative Law Judge
-- completed the form after observing what is attested to in the Emergency Evaluation?
Linda Gordon, Esquire, Public Defender
I have no evidence of that.
William L. England, Jr., Administrative Law Judge
All right. Thank you.
Linda Gordon, Esquire, Public Defender
I have no other questions of the record itself.
William L. England, Jr., Administrative Law Judge
All right. Call your first witness.
Thomas Lanz, Esquire, Attorney for the Hospital
I call Dr. Mullen.
William L. England, Jr., Administrative Law Judge
Well, doctor. Would you please state and spell your name for the record?
Joseph Mullen, M.D., First Year Resident
Dr. Joseph Mullen. M-U-L-L-E-N.
William L. England, Jr., Administrative Law Judge
You may proceed, doctor.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Dr. Mullen. When did you last evaluate Ms. Moran.
Joseph Mullen, M.D., First Year Resident
This morning.
Thomas Lanz, Esquire, Attorney for the Hospital
What's the current working diagnosis?
Joseph Mullen, M.D., First Year Resident
Bipolar affective disorder.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. She's still ... What physicians would term as in a manic state?
Joseph Mullen, M.D., First Year Resident
Hypomanic, yes.
Thomas Lanz, Esquire, Attorney for the Hospital
What is that what you mean by "hypomanic"?
Joseph Mullen, M.D., First Year Resident
Um. She's been hyperverbal. Intrusive. Sleep hasn't been all that great.
Thomas Lanz, Esquire, Attorney for the Hospital
Could you differentiate between being hypomanic and manic as it has been noted on the sheet of paper?
Joseph Mullen, M.D., First Year Resident
When she came in initially, she was very grandiose and very delusional. Believing that there was a conspiracy out there against her and she solved a crime.
Thomas Lanz, Esquire, Attorney for the Hospital
Doctor, I'm sorry, before we proceed. We can get to all that in a second. But what would differentiate her from being manic - in a manic episode as opposed to being in a hypomanic state as you indicated?
Joseph Mullen, M.D., First Year Resident
Um. There's a lessening in the delusions.
Thomas Lanz, Esquire, Attorney for the Hospital
All right. What medications is she currently prescribed?
Joseph Mullen, M.D., First Year Resident
She's getting lithium 600 twice a day. Risperdal 200 mg twice a day. And she's also getting Klonapin 0.5 mg twice a day.
William L. England, Jr., Administrative Law Judge
Make sure the doctor is picked up on the tape recorder. Capture your testimony.
Thomas Lanz, Esquire, Attorney for the Hospital
Is it lithium, Risperdal and Klonapin?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
Is she compliant with all these medications?
Joseph Mullen, M.D., First Year Resident
No.
Thomas Lanz, Esquire, Attorney for the Hospital
What medications has she been complying with?
Joseph Mullen, M.D., First Year Resident
She has been taking the lithium.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. And she takes it as directed, 600 mg twice a day?
Joseph Mullen, M.D., First Year Resident
Well, she's getting it 300, 300 and 600, actually. 600 is 1200 a day.
Thomas Lanz, Esquire, Attorney for the Hospital
1200 a day.
Joseph Mullen, M.D., First Year Resident
We broke it up to 300, 300 and 600.
Thomas Lanz, Esquire, Attorney for the Hospital
So she has been taking it as directed?
Joseph Mullen, M.D., First Year Resident
Yeah.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. She's refusing the Risperdal?
Joseph Mullen, M.D., First Year Resident
Correct.
Thomas Lanz, Esquire, Attorney for the Hospital
All right. And can you tell me a little bit about her mental status now as well as upon admission?
Joseph Mullen, M.D., First Year Resident
O.K. Well. Her hygiene is fair. When she talks, as I spoke, she's intrusive. We tried to discuss matters relating to her discharge and the criteria for that and she will interject. These types of delusions that she's working on changing the health care system as well as she single- handedly brought the ...
Nancy Moran, Patient
[unintelligible] ... Rite Aid Corporation
Joseph Mullen, M.D., First Year Resident
... yeah -- that's part of it.
Thomas Lanz, Esquire, Attorney for the Hospital
Did you state for the record your testimony is not outside ...
Joseph Mullen, M.D., First Year Resident
This morning she made reference to single-handedly disabling the defense system. Um. She also is dead set on buying Chinese food for the entire Unit using her credit card. That ... That fits into bipolar as well -- excessive spending. She's ...
Thomas Lanz, Esquire, Attorney for the Hospital
You talked about -- she had mentioned changing the healthcare system and disabling of the defense system. Is that part of her delusional process?
Joseph Mullen, M.D., First Year Resident
Correct.
Thomas Lanz, Esquire, Attorney for the Hospital
And based on your knowledge of bipolar affective disorder, what type of delusions would you consider those?
Joseph Mullen, M.D., First Year Resident
Grandiose.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Is that a symptom of someone with bipolar disorder?
Joseph Mullen, M.D., First Year Resident
Correct.
Thomas Lanz, Esquire, Attorney for the Hospital
And you also said excessive spending? Is that a symptom of bipolar disorder?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. What else can you tell us about Ms. Moran and how she would be dangerous if she were not in the hospital today?
Joseph Mullen, M.D., First Year Resident
O.K. She is showing a lack of insight, poor judgment, not taking her medications. She is delusional. This is delusional disorder one thing that we -- one way to control it acutely is to add on anti-psychotic which is the Risperdal and she is refusing to take that. Um. She seems to have generalized anxiety most of the times of day. She's irritating the Klonapin will help with that as well. And, outside of the hospital, she was a stage - she barricaded herself ...
Linda Gordon, Esquire, Public Defender
Objection. I don't believe there was any testimony to that effect.
William L. England, Jr., Administrative Law Judge
You can challenge that on cross-examination. He's testifying. He's sworn to testify truthfully. I don't think he's ... He may be mistaken, but there's no basis for objecting to it. You can cross-examine. The objection is overruled.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Doctor. Asking about the statements you just made ... Did you speak with anyone about Ms. Moran prior to - I mean - after she was here, did you get any collateral information from anyone?
Joseph Mullen, M.D., First Year Resident
Yeah ...
Thomas Lanz, Esquire, Attorney for the Hospital
Who did you speak with?
Joseph Mullen, M.D., First Year Resident
I spoke to her therapist.
Thomas Lanz, Esquire, Attorney for the Hospital
Who's that?
Joseph Mullen, M.D., First Year Resident
Her name is Sharon ... Her last name ...
Nancy Moran, Patient
Sharon Lerner?
Joseph Mullen, M.D., First Year Resident
Yeah. There we go.
Thomas Lanz, Esquire, Attorney for the Hospital
Who's the therapist?
Joseph Mullen, M.D., First Year Resident
Sharon Lerner. 701 West Pratt.
Thomas Lanz, Esquire, Attorney for the Hospital
This is Ms. Moran's outpatient therapist?
Joseph Mullen, M.D., First Year Resident
Correct.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. And you say you have collateral information about Ms. Moran?
Joseph Mullen, M.D., First Year Resident
Yeah.
Thomas Lanz, Esquire, Attorney for the Hospital
What did Ms. Lerner say about the events leading to this admission?
Joseph Mullen, M.D., First Year Resident
She stated that approximately five weeks prior to admission, Ms. Moran stopped taking her medication. She had stated that she had barricaded herself in the house, she was throwing things out the window, she was not showing up for appointments. She stated that she had lost approximately three pounds over a two week period. [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
So Ms. Lerner said that Ms. Moran was not feeding herself adequately.
Joseph Mullen, M.D., First Year Resident
Yes, she was sleeping poorly about four hours a night.
Thomas Lanz, Esquire, Attorney for the Hospital
All right. I'm just going to ask you a little bit about - what is your knowledge of someone with bipolar disorder also - your knowledge of Ms. Moran. Is a decrease in sleep perhaps it is consistent with the diagnosis of bipolar type?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
Especially someone who is in a manic state?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
And, so, Ms. Lerner had mentioned that she had barricaded herself in the house. What would be the rationale behind that?
Joseph Mullen, M.D., First Year Resident
With manic delusions, grandiosity, some people feel that they are target for large organizations. As she stated that she had solved a crime, but would not elaborate on that - there was a conspiracy theory.
Thomas Lanz, Esquire, Attorney for the Hospital
Based on your knowledge of Ms. Moran, do you feel that her barricading herself in her house and throwing things out her window are related to her delusions?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
Do you feel that it relates to her delusions that she expressed to you today?
Joseph Mullen, M.D., First Year Resident
Today?
Thomas Lanz, Esquire, Attorney for the Hospital
You had mentioned that she had mentioned a delusion about disabling the defense system and changing healthcare?
Joseph Mullen, M.D., First Year Resident
O.K. She had mentioned to me that she had very high profile people that [unintelligible] ... endangering herself. She had spoken to me about that this morning.
Thomas Lanz, Esquire, Attorney for the Hospital
Does Ms. Moran seem to be perceiving danger?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
All right. Has Ms. Moran expressed any interest in becoming a voluntary patient since she has been here?
Joseph Mullen, M.D., First Year Resident
Um. She's ...
Thomas Lanz, Esquire, Attorney for the Hospital
She doesn't wish to be a voluntary patient?
Have you approached ...
Joseph Mullen, M.D., First Year Resident
She's still [unintelligible] ...
Thomas Lanz, Esquire, Attorney for the Hospital
Um. O.K. Thanks. No further questions for Dr. Mullen.
William L. England, Jr., Administrative Law Judge
Cross-examination?
Linda Gordon, Esquire, Public Defender
Yes. Doctor, has she expressed any plan on how she is going to carry out any of the statements she made - disabling the defense system or changing the healthcare system?
Joseph Mullen, M.D., First Year Resident
These are things that she said. But in accordance to disabling the defense system, she said this was something that had been done. As far as the health system, healthcare system, she doesn't elaborate on it and when we sat down, her thoughts have been so loose that we really haven't been able to focus on targeted questions.
Linda Gordon, Esquire, Public Defender
So she said the defense system had already been disabled.
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
Did she say she had done this or somebody else had done this?
Joseph Mullen, M.D., First Year Resident
Yes. Yes. She mentioned that she had done it.
Linda Gordon, Esquire, Public Defender
Did she say how she did it?
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
And the defense system has not been disabled to your knowledge.
Joseph Mullen, M.D., First Year Resident
I don't know about the defense system.
Linda Gordon, Esquire, Public Defender
Do you know what defense system she was talking ...
Joseph Mullen, M.D., First Year Resident
She had made mention and I can't remember exactly the term that she used. Public Defense system is what she said. She was referring to Annapolis at the time. So I assumed ...
Nancy Moran, Patient
Oh - the ...
Linda Gordon, Esquire, Public Defender
So to your knowledge, she hasn't taken any action and you haven't other than her statement, you haven't heard of any action being taken in that regard by her.
Joseph Mullen, M.D., First Year Resident
Correct.
Linda Gordon, Esquire, Public Defender
O.K. And she doesn't to your knowledge have any kind of weapons in her house? Or any kind of - uh - explosives?
Joseph Mullen, M.D., First Year Resident
That hasn't been elaborated on. It's in the records and I haven't asked her since.
Linda Gordon, Esquire, Public Defender
So you have no information that would lead you to believe that, though.
Joseph Mullen, M.D., First Year Resident
Right. And I think that - uh -
Linda Gordon, Esquire, Public Defender
You have to say just yes or no for the tape.
Joseph Mullen, M.D., First Year Resident
O.K.
Linda Gordon, Esquire, Public Defender
O.K. So there is ...
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
No. O.K. Thanks. And has she made any threats to harm anyone here in the Hospital?
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
And she hasn't threatened to harm herself.
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
So she's not on suicide precaution.
Joseph Mullen, M.D., First Year Resident
Correct.
Linda Gordon, Esquire, Public Defender
She's not suicidal.
Joseph Mullen, M.D., First Year Resident
Correct.
Linda Gordon, Esquire, Public Defender
And here in the Hospital, is she able to feed herself and dress herself?
Joseph Mullen, M.D., First Year Resident
She's had - she's been feeding herself. Dressing herself.
Linda Gordon, Esquire, Public Defender
And you said that the therapist said she lost three pounds in two weeks.
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
She's not suffering from any kind of medical condition as a result of losing weight.
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
So she's not dehydrated or anemic.
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
There's no other medical condition that needs care.
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
And, at home, prior to her coming into the hospital, the Emergency Petition said she was disrobing. Do you have any information that would elaborate on that?
Joseph Mullen, M.D., First Year Resident
Nah, I don't.
Linda Gordon, Esquire, Public Defender
You don't know if she was disrobing in her house or where she was disrobing?
Joseph Mullen, M.D., First Year Resident
Right.
Linda Gordon, Esquire, Public Defender
And leaving the front door open, do you know when she did that?
Joseph Mullen, M.D., First Year Resident
That I don't know.
Linda Gordon, Esquire, Public Defender
Do you know how often that happened?
Joseph Mullen, M.D., First Year Resident
No, I don't.
Linda Gordon, Esquire, Public Defender
And walking the streets at night alone. Do you know when that happened? Do you know how often that happened?
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
Do you know if she was victimized in any way when she was walking the streets?
Joseph Mullen, M.D., First Year Resident
Not to my knowledge.
Linda Gordon, Esquire, Public Defender
And when you testified that the therapist said she barricaded herself in her house - do you know when that occurred?
Joseph Mullen, M.D., First Year Resident
Yeah, that occurred, I believe, -
[pause]
It was March 7th.
Linda Gordon, Esquire, Public Defender
March the 7th. And when you say "barricaded", what exactly is she alleged to have done?
Joseph Mullen, M.D., First Year Resident
She wasn't allowing anybody in. And ...
Linda Gordon, Esquire, Public Defender
So someone knocked on the door ...
Joseph Mullen, M.D., First Year Resident
Things were being thrown out the window.
Linda Gordon, Esquire, Public Defender
Do you know what was thrown?
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
Do you know if it was clothing or ... pillows? You don't know.
O.K. And no one was injured?
Joseph Mullen, M.D., First Year Resident
Not to my knowledge.
Linda Gordon, Esquire, Public Defender
And this was her home. She wasn't in someone else's house.
Were the police involved.
Joseph Mullen, M.D., First Year Resident
She had to be - The police just dropped by her therapist, though.
Linda Gordon, Esquire, Public Defender
But I mean on that particular incident, right then, immediately. Did the police get involved? Were the police called and responded to the scene?
Joseph Mullen, M.D., First Year Resident
[pause]
Linda Gordon, Esquire, Public Defender
You don't know. She hasn't been charged with any crime, though. And she wasn't injured in any way.
Joseph Mullen, M.D., First Year Resident
Not to my knowledge. No.
Linda Gordon, Esquire, Public Defender
And then, it wasn't until the next day on the 8th when the Emergency Petition was prepared.
William L. England, Jr., Administrative Law Judge
You have to say yes or no, doctor.
Joseph Mullen, M.D., First Year Resident
Yes.
William L. England, Jr., Administrative Law Judge
The tape recorder won't pick up a [unintelligible].
Linda Gordon, Esquire, Public Defender
O.K. Thank you.
Did she actually buy food for the whole unit?
Joseph Mullen, M.D., First Year Resident
Uh - she never did.
Linda Gordon, Esquire, Public Defender
You need to just testify from what you personally know.
Joseph Mullen, M.D., First Year Resident
O.K. Um -
Linda Gordon, Esquire, Public Defender
If you don't know.
Joseph Mullen, M.D., First Year Resident
It was on a weekend so I ...
Linda Gordon, Esquire, Public Defender
O.K. The delusions that you mentioned - can you explain how they cause her to be a danger to herself or others?
Joseph Mullen, M.D., First Year Resident
It's a - she's not able to care for herself in that she's not taking her medications. She's isolating herself from the world. She's paranoid. She's not taking her medications, she's not going to the [unintelligible]. She has approximate a twenty-two year history of bipolar affective disorder.
Linda Gordon, Esquire, Public Defender
Do you know how many appointments she missed, let's say within the last couple of months? Specifically?
Joseph Mullen, M.D., First Year Resident
I don't know the numbers.
Linda Gordon, Esquire, Public Defender
Was she supposed to go once a week?
Joseph Mullen, M.D., First Year Resident
That, I'm not sure.
Linda Gordon, Esquire, Public Defender
Did the therapist that you talked to say that she had missed more than one appointment or just one appointment?
Joseph Mullen, M.D., First Year Resident
Not one.
Linda Gordon, Esquire, Public Defender
But she didn't tell you numbers.
Joseph Mullen, M.D., First Year Resident
Right.
It was approximately five weeks that she wasn't taking any lithium. She told me that. The appointments had stopped.
Linda Gordon, Esquire, Public Defender
So she had stopped lithium for five weeks. Was she prescribed the Risperdal and the Klonapin as an outpatient?
Joseph Mullen, M.D., First Year Resident
The Klonapin, yes.
Linda Gordon, Esquire, Public Defender
Had she taken it as an outpatient?
Nancy Moran, Patient
Wrong!
Linda Gordon, Esquire, Public Defender
Just let him testify, would you?
Nancy Moran, Patient
O.K. That's wrong!
Joseph Mullen, M.D., First Year Resident
Yeah.
Linda Gordon, Esquire, Public Defender
She has been ...
Joseph Mullen, M.D., First Year Resident
She was ...
Linda Gordon, Esquire, Public Defender
You don't know if she was compliant?
Joseph Mullen, M.D., First Year Resident
[unintelligible]
Linda Gordon, Esquire, Public Defender
Is Klonapin a benzo?
Joseph Mullen, M.D., First Year Resident
Yes. Actually, she was negative for that.
Linda Gordon, Esquire, Public Defender
O.K. So you don't think she had taken it.
Joseph Mullen, M.D., First Year Resident
Right.
Linda Gordon, Esquire, Public Defender
So the Risperdal and the Klonapin are something new that she has been prescribed since her admission.
Joseph Mullen, M.D., First Year Resident
Correct.
Linda Gordon, Esquire, Public Defender
And did she say why she's been refusing to take those two medications?
Joseph Mullen, M.D., First Year Resident
No.
Linda Gordon, Esquire, Public Defender
Has she taken it at all or ...
Joseph Mullen, M.D., First Year Resident
Intermittently, yes.
Linda Gordon, Esquire, Public Defender
O.K. She takes sporadically. But she takes her lithium completely, every dose.
Joseph Mullen, M.D., First Year Resident
She has been to my knowledge.
Linda Gordon, Esquire, Public Defender
O.K. Has she improved since her admission?
Joseph Mullen, M.D., First Year Resident
There's been some reorganization. Some increase in organization.
Linda Gordon, Esquire, Public Defender
And what does that mean in layman's terms?
Joseph Mullen, M.D., First Year Resident
That means she's able to stay on target when we talk. Somewhat more. Make relevant comments secondary to questions being asked. And that's just a slight increase in that.
Linda Gordon, Esquire, Public Defender
If she were retained today, how long would you anticipate she'd need to be in the hospital?
Joseph Mullen, M.D., First Year Resident
I would hope that if she would decide to take her medications, that within a week or two she would be able to be released.
Linda Gordon, Esquire, Public Defender
Do you have any treatment plan for how you would get her to take her medication if she refuses.
Joseph Mullen, M.D., First Year Resident
Right now, no.
Linda Gordon, Esquire, Public Defender
You don't intend to submit her case to a clinical review panel?
Joseph Mullen, M.D., First Year Resident
If, if she is retained, yes.
Linda Gordon, Esquire, Public Defender
Thank you, doctor, I don't have any other questions.
William L. England, Jr., Administrative Law Judge
I fall now, redirect. I use this opportunity to ask any questions that I have. That way, each party can ask follow-up questions, if they have any. I will redirect and re-cross.
Doctor, make sure I understand your testimony. The testimony is that the patient stopped taking medication five weeks ago and as far as you know, the medications prescribed at that time were lithium and Klonapin. So she stopped taking both as far as you know.
O.K. Now since being hospitalized, your testimony is that she is taking the lithium but refused to take the other two which you prescribed ...
Joseph Mullen, M.D., First Year Resident
Not initially.
William L. England, Jr., Administrative Law Judge
Not initially.
Joseph Mullen, M.D., First Year Resident
... she started taking it consistently. Last Monday, she started taking the lithium. That's why her court hearing was postponed.
William L. England, Jr., Administrative Law Judge
When you say "court hearing", are you talking about THIS hearing?
Joseph Mullen, M.D., First Year Resident
Yes, She said that she would take the medication [unintelligible] ...
William L. England, Jr., Administrative Law Judge
Well, technically, it's not a court hearing. It's not a trial. But I understand you're not an attorney.
Hearing on behalf of the court will [unintelligible]
The refusal to take the medications - is that a manifestation of a mental disorder?
Joseph Mullen, M.D., First Year Resident
Yes.
William L. England, Jr., Administrative Law Judge
Now, I think you testified to this - not eating and sleeping poorly. Is that also a manifestation of a mental disorder?
Joseph Mullen, M.D., First Year Resident
Yes.
William L. England, Jr., Administrative Law Judge
And - if she continues just takes lithium but not the other two, will she still suffer the manifestations of the mental disorder?
Joseph Mullen, M.D., First Year Resident
She will gain somemore insight ...
William L. England, Jr., Administrative Law Judge
My question is, if she takes the lithium but refuses to take the other two as you testified she's been now ...
Would she still be suffering from the manifestations of the mental disorder that you described - lost weight, sleeping poorly ...
Joseph Mullen, M.D., First Year Resident
Delusional ...
William L. England, Jr., Administrative Law Judge
Yes.
Joseph Mullen, M.D., First Year Resident
That might come around with lithium alone. You would have ...
William L. England, Jr., Administrative Law Judge
I see.
Redirect [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
I have no more questions for Dr. Mullen on cross-examination.
Linda Gordon, Esquire, Public Defender
Yes, I do. When I questioned you on cross, I asked you whether or not she'd been prescribed Risperdal and Klonapin as an outpatient and I thought you had said no, she had not been.
Joseph Mullen, M.D., First Year Resident
O.K. She had not been Risperdal ... [unintelligible]
Linda Gordon, Esquire, Public Defender
O.K. So, just so we're clear, it was your understanding that her outpatient doctor had prescribed lithium and Klonapin.
Joseph Mullen, M.D., First Year Resident
It was my understanding.
Linda Gordon, Esquire, Public Defender
But she hadn't taken the Klonapin?
Joseph Mullen, M.D., First Year Resident
O.K.
Linda Gordon, Esquire, Public Defender
Do you know? Or, I don't want you to guess ...
Joseph Mullen, M.D., First Year Resident
Right. Well I'm almost certain ...
[pause]
William L. England, Jr., Administrative Law Judge
We're back on the record.
Linda Gordon, Esquire, Public Defender
O.K. So she had not been taking Klonapin prior to this. It is your understanding that her doctor had prescribed Ambien, not Klonapin.
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
O.K. So she had been prescribed lithium and Ambien and that is, is that along the same lines as Klonapin?
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
O.K. Anyway, so she was compliant with her medication up until five weeks ago and that was just the lithium and the Ambien.
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
... and nortriptyline ...
Nancy Moran, Patient
... wasn't indicated, wasn't indicated ...
Linda Gordon, Esquire, Public Defender
I'm sorry, I'm not following you ...
Joseph Mullen, M.D., First Year Resident
It was also loxapine and one ... it was written for ... written by her ...
Linda Gordon, Esquire, Public Defender
Are you saying that she was prescribed that medication or that it was present in her tox screen?
Joseph Mullen, M.D., First Year Resident
Current medications. It's written on 3/7/01 lithium, nortriptyline, loxapine, Ambien.
Linda Gordon, Esquire, Public Defender
O.K. Was it your understanding that she was compliant with those medications prior to her admission?
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
And, you said initially when she came to the hospital that she had not been eating at home as much as was adequate. During her stay here since the 8th, has she been eating here at the hospital?
Joseph Mullen, M.D., First Year Resident
Yes, she has.
Linda Gordon, Esquire, Public Defender
So that's not an issue. And has her sleep improved here in the Hospital?
Joseph Mullen, M.D., First Year Resident
It has improved somewhat, yes.
Linda Gordon, Esquire, Public Defender
Does she sleep at night and she's awake during the day?
Joseph Mullen, M.D., First Year Resident
She's had some problems with when she was sleeping too much during the day, and we have knocked her down her Klonapin to 125 at night.
Linda Gordon, Esquire, Public Defender
Does that have a sedative effect?
Joseph Mullen, M.D., First Year Resident
Yes, it does.
Linda Gordon, Esquire, Public Defender
And does that seem to help with the sleeping at night?
Joseph Mullen, M.D., First Year Resident
That has helped her not use her [unintelligible] during the day.
Linda Gordon, Esquire, Public Defender
Has it helped her to sleep more thoroughly at night? You have to say yes or no.
Joseph Mullen, M.D., First Year Resident
Yes.
Linda Gordon, Esquire, Public Defender
O.K. So her sleep has improved and her eating is fine. And when the Judge asked you whether or not the lithium alone could resolve her symptoms as far as the eating and the sleeping, it sounds like those symptoms have resolved - on the lithium. Is that fair to say?
Joseph Mullen, M.D., First Year Resident
[unintelligible]
Linda Gordon, Esquire, Public Defender
Yes, the eating and the sleeping.
Joseph Mullen, M.D., First Year Resident
Yes. I guess that is true.
Linda Gordon, Esquire, Public Defender
But the delusions have not ... [change of tape side]
Could the lithium possibly address the delusional status or is that something that you have to have these other medications for?
Joseph Mullen, M.D., First Year Resident
It's a manifestation of the bipolar disorder alone. It's not [unintelligible]
Linda Gordon, Esquire, Public Defender
Do you know yet whether hers is a thought disorder or not?
Joseph Mullen, M.D., First Year Resident
Well, due to her disorganization, I don't know whether there is a thought disorder or not. It's not just secondary to mania ...
Linda Gordon, Esquire, Public Defender
So you can't say for sure whether the other medications ...
Joseph Mullen, M.D., First Year Resident
The Risperdal is also used for mania.
Linda Gordon, Esquire, Public Defender
But you can't say for sure whether those medications will resolve her delusional symptoms.
Joseph Mullen, M.D., First Year Resident
Say that again.
Linda Gordon, Esquire, Public Defender
You can't say for sure whether the additional medications will resolve her delusional behaviors.
Joseph Mullen, M.D., First Year Resident
That's fair. That is what they're used for.
Linda Gordon, Esquire, Public Defender
But you don't know whether or not they'll work with her.
Joseph Mullen, M.D., First Year Resident
You can say that about any [unintelligible], yes.
Linda Gordon, Esquire, Public Defender
All right. Thank you, doctor.
Thomas Lanz, Esquire, Attorney for the Hospital
Just one question for doctor Mullen. Would you, doctor, is this medication Risperdal, ...
Joseph Mullen, M.D., First Year Resident
Risperdal.
Thomas Lanz, Esquire, Attorney for the Hospital
Would Mrs. Moran's delusions be considered a psychotic symptom?
Joseph Mullen, M.D., First Year Resident
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
What is the goal by prescribing Risperdal if the psychotic symptoms would improve? If she takes the Risperdal?
Joseph Mullen, M.D., First Year Resident
Correct.
Thomas Lanz, Esquire, Attorney for the Hospital
That's all I have for Dr. Mullen.
William L. England, Jr., Administrative Law Judge
Any more witnesses?
Thomas Lanz, Esquire, Attorney for the Hospital
Yes, Dr. Adebuiwa. Could you please state your name and relationship to Ms. Moran?
William L. England, Jr., Administrative Law Judge
Spell your name for the record, ma'am.
Angela Udebiuwa, M.D., Attending Physician
Dr. Angela Udebiuwa. Last name is U-D-E-B-I-U-W-A. I am attending psychiatrist for Mrs. Moran.
Thomas Lanz, Esquire, Attorney for the Hospital
Are you a licensed physician to practice medicine in the State of Maryland?
Angela Udebiuwa, M.D., Attending Physician
Yes, man.
Thomas Lanz, Esquire, Attorney for the Hospital
And when did you last evaluate Ms. Moran?
Angela Udebiuwa, M.D., Attending Physician
This morning.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Are you in agreement with the working diagnosis of bipolar disorder.
Angela Udebiuwa, M.D., Attending Physician
Bipolar disorder with [unintelligible] features.
Thomas Lanz, Esquire, Attorney for the Hospital
And it is your understanding that Ms. Moran is refusing Risperdal and Klonapin and taking them sporadically and taking her lithium.
Angela Udebiuwa, M.D., Attending Physician
Yes, she is taking her lithium and refusing her Risperdal and [unintelligible] and the Klonapin is [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
Based on your knowledge of Ms. Moran, could you please elaborate a little bit on her delusions and why she is a danger to herself or others if she is discharged today?
Linda Gordon, Esquire, Public Defender
Objection. Dr. Mullen has already testified to that. I think that it wouldn't really be fair to the patient to have another doctor testify to the same criteria if Dr. Adebuiwa has additional information that she would like to add that wasn't addressed by Dr. Mullen, I wouldn't object to that. But I object to her going over the criteria again.
William L. England, Jr., Administrative Law Judge
Very well. I guess the only rational forte is that it's a waste of judicial - it's a waste of time, a waste of judicial resources - but I don't see how it is in any other way, prejudicial to the patient. Dr. Adebuiwa has stated that she is the treating psychiatrist. For that reason, I'm willing to spend the time as necessarily. As I've told you, the objection is overruled.
Thomas Lanz, Esquire, Attorney for the Hospital
You want me to restate the question, please?
Linda Gordon, Esquire, Public Defender
Please.
Thomas Lanz, Esquire, Attorney for the Hospital
Based on what you know and her treatment here, please tell us a little bit about her delusional process and how it has as well as any other symptoms make her a danger if she is discharged today.
Angela Udebiuwa, M.D., Attending Physician
It is my [unintelligible] doing very well [unintelligible] continuing for a long time. Somebody who has worked it over the years. It's not the first admission here. And Ms. Moran currently has delusions - a problem because Ms. Moran does not have any insight into the -- into this poor insight and her poor judgment that brings her into the hospital in the first place.
She barricaded herself in her house four days prior to admission. She has been non- compliant with her medications four weeks prior to admission. She has a slow decline in her bodily function in terms of grooming herself, eating - she wasn't eating - she lost weight. She had developed poor hygiene. She was wandering in the streets found by Dwain Howard, her counselor assigned by Harbor City.
She was also drinking prior to admission. She was admitted so she admitted herself to drinking at least four quarters of beer daily which she does this. Ms. Moran does have an alcohol problem.
I'm concerned that Ms. Moran has exhibited very poor judgment, very common sign of this practically [unintelligible] ...
Since she has been here, the insight has been changed. So affect would be, well, that would be judgment. Judgment hasn't changed, either. I mean, Ms. Moran has a lot of support on the outside. She has wonderful treatment. She has a therapist and a psychiatrist. She sees people at Harbor City. Dwain is a very useful member and she was unable to use it prior to this admission.
So she comes into inpatient where there is 24-hour supervision. She still has no insight and it is agreed that she was dressed in better now that she is in her new but her meals are being prepared for her. Additionally, the information I have prior to admission is that when Ms. Moran came into the Hospital, prior to coming into the Hospital, she was barricading herself into her room and throwing things outside. She also invited a stranger into her home a few days prior to admission. I don't have the exact dates.
This stranger was later found to be an ex-con. So the trouble is that it is very often that when she gets adequate treatment, she is able to function in her own resources that are available to her.
Another thing which concerns her in terms of [unintelligible] is that her family doesn't live in the area. Her sister lives in Chicago. Her sister is somebody we know very well - with her last admission. She has very supportive family but what we have seen right now is that Ms. Moran is unable to care for her. She has no insight [unintelligible]. She wasn't caring for herself practically outside the hospital. She is now trying to do it in a supervised setting. Ms. Moran's lunch is ready. Ms. Moran's breakfast is ready. Ms. Moran is taking a shower. This is a supervised 24-hour setting. And she is still ill. [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. And it is your belief that she does require 24-hour care and supervision?
Angela Udebiuwa, M.D., Attending Physician
At this time, yes.
Linda Gordon, Esquire, Public Defender
Given the medications as prescribed?
Thomas Lanz, Esquire, Attorney for the Hospital
Is it your belief the fact that Ms. Moran is in this locked, 24-hour supervised setting that's preventing Ms. Moran from being in a dangerous situation?
Angela Udebiuwa, M.D., Attending Physician
Yes. It is my belief given the evidence that we have prior to her admission.
Thomas Lanz, Esquire, Attorney for the Hospital
So, is it your further belief that she requires further inpatient institutional care?
Angela Udebiuwa, M.D., Attending Physician
She does. She requires inpatient - she requires further inpatient and family institutional care. But she does get that - but she's not taking her medications. And I'm planning to go ahead and see what we can have her [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
And with regard to Ms. Moran, in her current condition, would her psychosis - her delusions - her delusional process - would they improve with her just taking lithium alone?
Angela Udebiuwa, M.D., Attending Physician
No. [unintelligible] Ms. Moran knows - that we have a multi-strong very well antipsychotic. She's done that in the past. We can't do this outpatient against the [unintelligible] the lithium ... the bipolar [unintelligible] ... The best that we know about Ms. Moran is that past treatment she's been [unintelligible] for very long time. She does very well on antipsychotic in the initial stages and once her delusional stage is under control, then, the bipolar is again stabilized. She is a very, very functional woman.
Thomas Lanz, Esquire, Attorney for the Hospital
Dr. Mullen testified that there had been some mild improvement, and said that Ms. Moran was more organized. Would you agree with that statement?
Angela Udebiuwa, M.D., Attending Physician
I would agree that she is able to sit longer in groups now. She is a little bit more organized. She's less manicky and less intrusive. But I think she remains she is consistent with very psychotic. She continues to remain intrusive. Making comments to other patients. Interrupting the routine. And before she can even do for half a second, and now she can sit down and talk with you for a little bit more than half a second or a minute, too. Before, she was unable to do that. She was very intrusive.
Thomas Lanz, Esquire, Attorney for the Hospital
And, based on all of that - do you feel that Ms. Moran is ready - is stabilized enough for a less restrictive environment?
Angela Udebiuwa, M.D., Attending Physician
Not at this time and I am hoping that she want to take the medication in a few more days so that we may -
We know that Ms. Moran can do better than this and we'll get together to keep [unintelligible]
Thomas Lanz, Esquire, Attorney for the Hospital
Is it your belief that she isn't ready for a less restrictive environment. Is that based on her poor insight and judgment?
Angela Udebiuwa, M.D., Attending Physician
Poor insight and judgment and refuses to take her medications. She is not good at taking [unintelligible] a 24-hour unit but you put a [unintelligible] and encourage her with providing her with information, I doubt what she is going to take once she leaves the hospital.
Thomas Lanz, Esquire, Attorney for the Hospital
Thanks. No further questions.
Linda Gordon, Esquire, Public Defender
Yes. Um. Doctor, the issue of whether or not she was feeding herself at home, do you have any information on how many meals she was eating, whether she was preparing meals just prior to her admission?
Angela Udebiuwa, M.D., Attending Physician
No. I do not think that how many meals she was taking, no I do not.
Linda Gordon, Esquire, Public Defender
Three pounds in a two week period. Isn't of any real significance, medically, is it?
Angela Udebiuwa, M.D., Attending Physician
No. Not really but if the conservative trend continues, Ms. Moran is fortunate to have a great system on the outside that checks up on her so frequently. If she didn't have that kind of support, this trend could be three pounds this week and then three pounds the following week and ten pounds the following week and we don't know. She was brought in here because people were able to observe that she planned function secondary to medication oversight. She was brought in here before because it got to a point where she was medically an emergency.
Linda Gordon, Esquire, Public Defender
Was there any indication that she didn't have food in her house?
Angela Udebiuwa, M.D., Attending Physician
No.
Linda Gordon, Esquire, Public Defender
Was there any indication that her house was infested with vermin?
Angela Udebiuwa, M.D., Attending Physician
Yes. She had mice in her house and she refused to get rid of the mice because she didn't want to do that. There was mice in the house and the house was infested.
Linda Gordon, Esquire, Public Defender
You know how many mice?
Angela Udebiuwa, M.D., Attending Physician
[unintelligible]
Linda Gordon, Esquire, Public Defender
You don't know whether she has a few mice in her home.
Angela Udebiuwa, M.D., Attending Physician
Not that I know, but it got to the point where she complained to her therapist that she's having difficulty sleeping with the mice. The therapist said get out of the house and get somebody in to clean up the mice. And she refused to do that.
Linda Gordon, Esquire, Public Defender
And was she responsible for taking care of the house?
Angela Udebiuwa, M.D., Attending Physician
She lives alone.
Linda Gordon, Esquire, Public Defender
O.K. This is her house.
Angela Udebiuwa, M.D., Attending Physician
This is her house.
Linda Gordon, Esquire, Public Defender
And the - your statement that she invited a stranger into her home -
Angela Udebiuwa, M.D., Attending Physician
Yes, she did.
Linda Gordon, Esquire, Public Defender
Do you know where she met this person?
Angela Udebiuwa, M.D., Attending Physician
No, I do not. I do not have the details of the concern of the treatment team.
Linda Gordon, Esquire, Public Defender
I'm just asking you that question where she meant -
Is there any indication as to why she invited him to her house?
Angela Udebiuwa, M.D., Attending Physician
No. No.
Linda Gordon, Esquire, Public Defender
And was she victimized in any way by him?
Angela Udebiuwa, M.D., Attending Physician
I don't have that.
Linda Gordon, Esquire, Public Defender
She didn't tell you that she was. And he just left and that was the end of it?
Angela Udebiuwa, M.D., Attending Physician
That is my understanding [unintelligible]
Linda Gordon, Esquire, Public Defender
O.K. And do you know whether she's on a therapeutic level if lithium now?
Angela Udebiuwa, M.D., Attending Physician
The last time we checked her level it was non-therapeutic. It was 0.5 but we increased her dose and we're hoping that by about tomorrow, we will check it again.
Linda Gordon, Esquire, Public Defender
O.K. Was it about a week ago that you checked it?
Angela Udebiuwa, M.D., Attending Physician
No, it wasn't quite that.
Linda Gordon, Esquire, Public Defender
And you have plans to take her lithium level tomorrow.
Angela Udebiuwa, M.D., Attending Physician
Uh-huh. If it's five days from the [unintelligible]
Linda Gordon, Esquire, Public Defender
O.K. Thank you doctor, I don't have anything else.
William L. England, Jr., Administrative Law Judge
I have this question. I'm not sure I understand exactly the testimony of the doctor.
These behaviors that you testified regarding wandering in the streets, let's just go back to the alcohol for the moment. Inviting strangers to the home. The house being unkempt. Is that a manifestation of a mental disorder?
Angela Udebiuwa, M.D., Attending Physician
That it would be.
William L. England, Jr., Administrative Law Judge
All right. Now as to consuming alcohol, I mean that alcohol is not a mental disorder as I understand it. But, I mean, can you separate the consuming alcohol from alcoholism or what you just testified to being a manifestation of a mental disorder?
[several voices at once]
You testified among the several behaviors. One in the street, inviting a stranger to home, ... And I ask if that is a manifestation of a mental disorder which has been diagnosed as bipolar affective disorder with psychotic features. And you said, yes.
Now, you had also testified that she was consuming alcohol. And my question is is that a manifestation of a mental disorder?
Angela Udebiuwa, M.D., Attending Physician
She does, in her case, it may not necessarily be a manifestation, but she does have a history of alcohol use. It is an indication to what's her poor judgment. Ms. Moran doesn't drink alcohol when she stays on her medications. She does it once at a time on drinking. And it is an indication that she's falling back when she's not stopped drinking as much as four point ounces a day, which she is reporting prior to coming in to her therapist after giving her indication that her judgment, in addition to all this other information. Her judgment is off. And she's now doing behavior that would indicate that she would not normally do when her judgment is on target.
William L. England, Jr., Administrative Law Judge
So your testimony is that she's not compliant with medication. She is not helpful ...
Angela Udebiuwa, M.D., Attending Physician
No.
Nancy Moran, Patient
Wrong!
Angela Udebiuwa, M.D., Attending Physician
William L. England, Jr., Administrative Law Judge
So she's not alcoholic. Is she?
Angela Udebiuwa, M.D., Attending Physician
True. I don't have to be exact but I do know that when she would go back to the outside drinking is one of her problems and I spoke with Sharon Lerner at 701 Pratt.
When she is not drinking totally, I can't say [unintelligible] ...
William L. England, Jr., Administrative Law Judge
And it's your matter of opinion that she would not be compliant with medications as of right now.
Angela Udebiuwa, M.D., Attending Physician
Yes. Because she's not in the hospital ...
William L. England, Jr., Administrative Law Judge
I see.
Any redirect, Mr, Lanz?
Thomas Lanz, Esquire, Attorney for the Hospital
No.
William L. England, Jr., Administrative Law Judge
Any recross to my question.
Linda Gordon, Esquire, Public Defender
No.
I'd make a motion at this time for Ms. Moran to release. I'd like to reserve the right for her to testify depending on how you rule. However, since the Hospital has rested its case, I think it would be an appropriate time to decide that issue.
William L. England, Jr., Administrative Law Judge
O.K. Well I'm going to deny the motion at this point.
Linda Gordon, Esquire, Public Defender
O.K. Then I'll have Ms. Moran testify.
Nancy Moran, Patient
Sharon Lerner, what is her education?
Linda Gordon, Esquire, Public Defender
No, no, no. I'm going to ask you some questions.
Nancy Moran, Patient
Oh. O.K.
Linda Gordon, Esquire, Public Defender
O.K.? Um, first of all, the doctor, both of the doctors testified that you had lost weight just prior to your admission and that you weren't sleeping. Had you not been eating?
Nancy Moran, Patient
No, I was sleeping very well. I was utilizing - I was up into the night. Wee hours of the night. It was a regular work schedule. And, around dawn, I would either go off to sleep and sleep between 6 am and noon. And, occasionally, from time to time, on a periodic basis, I would take Ambien 5 mg the generic name for Ambien is zolpidem tartrate. It is far better than Klonapin, and it does not build up tolerance.
Linda Gordon, Esquire, Public Defender
And that has been prescribed by your outpatient doctor?
Nancy Moran, Patient
Yes. By Dr. Balis.
Linda Gordon, Esquire, Public Defender
O.K. And had you lost any significant amount of weight over the last two weeks?
Nancy Moran, Patient
I was using a scale that had not been calibrated. I was not using a professional scale the way I was using the white one that goes underneath the desk and underneath the fax machine where the zero rating is like at 6 below the zero.
Linda Gordon, Esquire, Public Defender
You mean in your outpatient's doctor's office?
Nancy Moran, Patient
No, this inpatient, when I weighed myself.
Linda Gordon, Esquire, Public Defender
Oh, O.K. Um. They also claimed that you barricaded yourself in the house and were throwing things out the window at people. That's another ...
Nancy Moran, Patient
I live and work at the second floor. I have a rowhouse. My computer room, my bedroom, my fax room, my work room, my clothes, my library, my office files are on the second floor. So when the doorbell rings, I open a window and say, "Who's that out there?" I'm not barricading myself. I'm just not going to get dressed and go all the way down ...
Linda Gordon, Esquire, Public Defender
So you hadn't lied to the Jehovah Witness standing. You hadn't pushed furniture against the door ...
Nancy Moran, Patient
Zero. Nothing.
Linda Gordon, Esquire, Public Defender
So the door was just ...
Nancy Moran, Patient
Nothing ...
Linda Gordon, Esquire, Public Defender
And did you throw anything at any people?
Nancy Moran, Patient
Yes. I've been very ... That's part of problem that I wanted to get of the witnesses in the killing on my behalf in that neighborhood.
Linda Gordon, Esquire, Public Defender
What did you throw out the window?
Nancy Moran, Patient
A cigarette. Well I have people and I have been working in the prison system since 1980 ... December of 1980. Shall I give you references from Bishop Robinson on down.
Linda Gordon, Esquire, Public Defender
Let me just focus of the cigarette. You threw a cigarette out the window?
Nancy Moran, Patient
On the way, I had to demonstrate to DeGuzman, because she isn't bright.
Linda Gordon, Esquire, Public Defender
So an unlit cigarette.
Nancy Moran, Patient
They come to me for cigarettes, and at Christmas I give them some quarters and some candies and a cigarette, and I put it out, and I drop it out the window. That's Christmastime in West Baltimore.
Linda Gordon, Esquire, Public Defender
O.K. You didn't throw any furniture or weapons or anything?
Nancy Moran, Patient
No. And another one, when he does my walkway, my walkway shows up and he gets a pack for that. "I don't want a pack - I want three dollars". "I can only give you two dollars and ten cigarettes." "O.K. Give him a pack" "Let me see ... O.K." Then I throw the pack out the window. That's how you get your stoops done.
Linda Gordon, Esquire, Public Defender
So the therapist, when she said that you barricaded yourself and were throwing things out the window, you weren't throwing anything but a cigarette out the window?
Nancy Moran, Patient
Yeah. That's right. [unintelligible] was my closest personal friend for twenty-two years. Comes to my house. He rings the doorbell three times. I curse, because I'm usually asleep because it is in the morning. I drop the keys out the window.
Linda Gordon, Esquire, Public Defender
He didn't throw anything out the ...
Nancy Moran, Patient
He comes in with the keys and he puts them back. He puts the keys back through the door.
Linda Gordon, Esquire, Public Defender
He didn't throw anything at the therapist, Ms. Lerner, or any ...
Nancy Moran, Patient
Never. Never at any point and this [unintelligible] This is the first time I have seen or heard of that and will add it's a killing in the neighborhood.
Linda Gordon, Esquire, Public Defender
Let me just focus on this. As far as the appointments you had with your outpatient doctor. Did you miss any more than one?
Nancy Moran, Patient
No. I did miss two. But with Sharon Lerner. I called her. If I could not make it I called her and explained to her what it was and, once I got on the phone with the billing department ... I got on the phone with them and got caught for an hour trying to find out the bills ...
Linda Gordon, Esquire, Public Defender
So you would always let her know before you didn't show up ...
Nancy Moran, Patient
And in the event I forgot and mixed up the day or something came up, she would call me.
Linda Gordon, Esquire, Public Defender
O.K.
Nancy Moran, Patient
But recently she didn't three weeks with this baloney. I missed an appointment with both Balis and Lerner, never heard follow up from either of them.
Linda Gordon, Esquire, Public Defender
Did you call them?
Nancy Moran, Patient
No I didn't because things were happening neighborhood wise.
Linda Gordon, Esquire, Public Defender
So it was two appointments or three appointments?
Nancy Moran, Patient
No, it was just those two in the past five weeks.
Linda Gordon, Esquire, Public Defender
Two appointments.
Nancy Moran, Patient
Once with Lerner and one with Balis.
Linda Gordon, Esquire, Public Defender
O.K. So you didn't miss five appointments?
Nancy Moran, Patient
Over a three year period, yes.
Linda Gordon, Esquire, Public Defender
No I just mean over the past five weeks.
Nancy Moran, Patient
No ...
Linda Gordon, Esquire, Public Defender
Just one appointment with your therapist and one with your doctor.
Nancy Moran, Patient
Yeah. I didn't mean it. I didn't mean it.
Linda Gordon, Esquire, Public Defender
Were you continuing ...
Nancy Moran, Patient
It was a half an hour walk to get down there.
Linda Gordon, Esquire, Public Defender
The doctors testified that you had stopped taking your lithium about five weeks before you came in the hospital?
Nancy Moran, Patient
So with what was happening, I have these pill cups. I was having the pill cup routine. I found myself skipping mornings. And I found myself skipping like four in a week and finally, it got to what about Seven. That's what was happening. And what a lot of bipolar people do is when they know they're going up for lab tests. Three days before the test, they take what they're supposed to take. What they're prescribed to take. Regardless of how much eating or drinking or exercise or anything else that were doing. Then they take the test and it ends up in the right range and the doctor nods and then the person goes back to not taking the lithium. This is like a principle of chemistry at the basal level.
Linda Gordon, Esquire, Public Defender
Ms. Moran let me just get to ...
Nancy Moran, Patient
I tried to demonstrate to Dr. Guzman, who's got to go a long way before she's going to qualify to be called M.D.
Linda Gordon, Esquire, Public Defender
Ms. Moran, did you take your lithium when you were supposed to just prior to your admission?
Nancy Moran, Patient
No I left off taking the whole ... I left out ... I started eating regularly. You go out, you order a calzone, a veggie calzone with sausage and pepperoni and it lasts five days. I was eating regularly, complete, balanced food. I was cooking lamb shops. I was ...
Linda Gordon, Esquire, Public Defender
If you left the hospital ...
Nancy Moran, Patient
I was stockpiling rice. I have meals in my freezer ready to go right now ...
Linda Gordon, Esquire, Public Defender
If you left the hospital ...
Nancy Moran, Patient
Appropriate meals.
Linda Gordon, Esquire, Public Defender
If you left the hospital, would you continue to take the lithium.
Nancy Moran, Patient
Yes.
Linda Gordon, Esquire, Public Defender
And you're taking it.
Nancy Moran, Patient
But, but ...
Linda Gordon, Esquire, Public Defender
Six hundred milligrams.
Nancy Moran, Patient
I finally got down and dirty instead of playing dirty and taking it all and falling within the right range ...
Linda Gordon, Esquire, Public Defender
What is the range of the ...
Nancy Moran, Patient
[unintelligible], period.
Linda Gordon, Esquire, Public Defender
You can't answer questions while you're testifying.
Nancy Moran, Patient
O.K. Six-Oh. I was taking 900 at night, period, and nothing in the morning. I just was curious. What the hell is the level. And the level turned out below but it turned out in the same range and it turned out 0.7. And that proved to me that all these years of lithium levels because they're based on your hospitalization and not your outpatient was harming my kidneys.
Linda Gordon, Esquire, Public Defender
Right now, the doctor said you were not taking your Risperdal or Klonapin.
Nancy Moran, Patient
Risperdal is crap.
Linda Gordon, Esquire, Public Defender
Are there side effects.
Nancy Moran, Patient
Yes, it has immune sequelae. It creates topical dermatitis. This watch, when I was on it, would leave a mark. Bloating, O.K.
Linda Gordon, Esquire, Public Defender
I have tried it before ...
Nancy Moran, Patient
I had pains here in the lymph areas where the lymphs meet the fluids of the breasts. Here. When I took Risperdal. I'm not taking Risperdal. That is shit and I know why it is shit.
Linda Gordon, Esquire, Public Defender
And have you tried Klonapin in the past.
Nancy Moran, Patient
Yes, Laura Gaffney, who was another doctor I had as an outpatient. She was having trouble really knowing what to do and there was some bugaboo about Halcion when you use the Halcion you will know about the bugaboo about what was too expensive. That's not our drug company in this Hospital. So she said, "Try the Klonapin" and it was great.
Linda Gordon, Esquire, Public Defender
So would you be willing to try the Klonapin again?
Nancy Moran, Patient
Yeah, I've been doing it. What is it about the goddam Klonapin - you don't take it in the morning. You take it at bedtime. And if your bedtime is midnight, you don't take it at 9 because your blood level goes down by midnight and it doesn't work and you end up talking to the night nurse at 4 in the morning. So you're without being able to sleep.
Linda Gordon, Esquire, Public Defender
You're willing to continue to take the Klonapin on an outpatient basis.
Nancy Moran, Patient
Yes. But it's gonna - it develops a tolerance. It ceases to work. It's an excellent pharmaceutical. It just is not better than nine weeks after that, you've got to go to something else. And the something else is Ambien. What is wrong with Ambien? What's wrong with GD Searle Corporation?
Linda Gordon, Esquire, Public Defender
Ms. Moran. I have no other questions for you, O.K.?
Now the Hospital may have some questions.
Thomas Lanz, Esquire, Attorney for the Hospital
Yeah, just a couple of things, Ms. Moran. You had talked about some of your doctors. You mentioned Dr. Balis. I think you mentioned Dr. Guzman.
Nancy Moran, Patient
Prior to that, Iacopovich.
Thomas Lanz, Esquire, Attorney for the Hospital
It seemed that you had some frustration with those doctors.
Nancy Moran, Patient
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
Part of the doctor's testimony was about you having some what they call delusions about the healthcare system. What would be your response to that?
Linda Gordon, Esquire, Public Defender
Objection, that's outside the scope of my direct.
William L. England, Jr., Administrative Law Judge
Sustained. She didn't ask about that.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Are you [unintelligible], your honor?
William L. England, Jr., Administrative Law Judge
So that when you respond to the objections.
Thomas Lanz, Esquire, Attorney for the Hospital
So Ms. Moran had expressed some frustration about her doctors. And perhaps that was part of - I felt that that allowed open for the scope of this question.
William L. England, Jr., Administrative Law Judge
I'll admit that.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Ms. Moran, you had mentioned working in the prison system since 1980. Are you still currently working?
Nancy Moran, Patient
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
What do you do for them?
Nancy Moran, Patient
I answer inmate mail. I have a couple of letters into Judge Bell about documents and paperwork and handwriting samples and things like that to Judge Bell. I also have a letter in about the entire District court system about ten pages which actually is posted on my Internet website. It's called "Essay on the District Courts".
Thomas Lanz, Esquire, Attorney for the Hospital
So you do actually work for the prison system or do you work ...
Nancy Moran, Patient
No, totally volunteer.
I'm living on a small trust my grandmother left me. And savings. And my house has no mortgage on it - I bought it outright.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. You had seemed to want to mention something. I wanted to give you the opportunity. It had been something in your neighborhood. Killing your neighbor on your behalf.
Nancy Moran, Patient
Yes, and I wanted and I think it is for the Baltimore City Police Force from that area.
As far as barricading, I know where that crap came from. Two women.
Linda Gordon, Esquire, Public Defender
I think you did explain that. What did you want to say about -
Thomas Lanz, Esquire, Attorney for the Hospital
Was there something you wanted to add? I mean we are not able to have a police officer. It seemed that you had wanted to say something about a killing on your behalf I thought you said.
Nancy Moran, Patient
Yes.
Thomas Lanz, Esquire, Attorney for the Hospital
Could you tell us a little about that?
Nancy Moran, Patient
Yes. I have two dogs and whatever and I've been an urban dweller before in the past. And I have very nice dogs, very wonderful, affectionate, not liable to bite. They currently don't growl. They are just wonderful dogs. And they have all their tags and numbers, phone numbers, everything.
They get out when you open the door for the garbage or you know, somebody, the mailman opens or something, they get out.
There was a crazed woman. A white woman. About five foot four and she was one night - BiBi was across the street barking and nobody in our block would care about it. Not within a hundred yards of my house. It was not that much barking.
She drove up and had me in her carlights. Told me to get down the stairs and I was in my robe. It was about 11:30 at night. She starts all of a sudden about dogs getting killed and going to animal control. Stepping on the accelerator, rushing down the street. Animal control.
And in the meantime, my fence - the kids kept getting to my fence to get to the shortcut to the other side. And the dogs would get out. They would come right back, they're very nice dogs.
And one night she came to me. The kids had gotten the door open - they got out - I didn't know.
Thank you for bringing them back. And she said, "It's the Seton Hill Neighborhood Association", as she drove her car, you know, zooming away the way Batman does.
Thomas Lanz, Esquire, Attorney for the Hospital
Ms. Moran, was there someone that was killed, you said on your behalf.
Nancy Moran, Patient
They killed her. I think they did, I'm pretty sure they did.
Thomas Lanz, Esquire, Attorney for the Hospital
Who was that?
Nancy Moran, Patient
Well, I'm also - because I've been in the prison system since 1980 it was normal for me to have people with prison records around. And I feed them and I give them little jobs and they do errands for me. And if I have a code I might give them to - I might let them use the telephone.
Thomas Lanz, Esquire, Attorney for the Hospital
So they, meaning someone that you ...
Nancy Moran, Patient
They pick up garbage. I pay them to do jobs and they escort me to the store and back. I'm white.
Thomas Lanz, Esquire, Attorney for the Hospital
So you feel like someone that you've interacted with killed this woman for you because she had been ...
Linda Gordon, Esquire, Public Defender
Objection. I don't ...
William L. England, Jr., Administrative Law Judge
Hold, hold just a minute.
Linda Gordon, Esquire, Public Defender
Supposing a great deal. O.K., I ...
William L. England, Jr., Administrative Law Judge
Well he can frame a question. What's the basis of your objection.
Linda Gordon, Esquire, Public Defender
That he was asking questions not in evidence.
Nancy Moran, Patient
I'm surmising, I'm not concluding.
Thomas Lanz, Esquire, Attorney for the Hospital
I can restate the question.
Ms. Moran, is it your belief that someone who you know killed this woman on your behalf?
Nancy Moran, Patient
She finally came up to my door and, "What is your name?" "Who are you?" And she said Cindy Curtin. And my dog was coming up the stoop and she took my dog by the collar. Not that she's ... She says, "Come on, you are going to Animal Control."
The dog was obeying me, coming up my own stoop. She says, "You are going to Animal Control." Meanwhile, around the City there are all sorts of pit bills and stuff.
So my outlook - I can operate in a maximum security prison and two-thirds of my neighbors have been in maximum security prisons.
Thomas Lanz, Esquire, Attorney for the Hospital
So you think that one of your neighbors killed this woman?
Nancy Moran, Patient
Yeah. [unintelligible]. There may have been other reasons, too. The whole Seton Hill group is all these white girls and they're bitches.
Thomas Lanz, Esquire, Attorney for the Hospital
O.K. Thanks.
Nancy Moran, Patient
That's why I know that ...
Linda Gordon, Esquire, Public Defender
Got it. All right.
William L. England, Jr., Administrative Law Judge
I have a couple of quick questions.
Ms. Moran, you testified that before you were hospitalized you stopped taking your lithium.
Nancy Moran, Patient
Yes.
William L. England, Jr., Administrative Law Judge
What other medications ...
Nancy Moran, Patient
Nortriptyline. The patent name is Pamelor.
William L. England, Jr., Administrative Law Judge
The one that you said you preferred.
Linda Gordon, Esquire, Public Defender
Ambien.
Nancy Moran, Patient
Oh, Ambien. It goes by the name ...
William L. England, Jr., Administrative Law Judge
Had you stopped taking that, too.
Nancy Moran, Patient
No, I was only taking it PRN. I was not taking it every single day. I would take my other pills ...
William L. England, Jr., Administrative Law Judge
You were taking that as prescribed, is that your testimony.
Nancy Moran, Patient
I was taking it according to doctor's dispense and instruction. It's a PRN. I don't just pop it automatically, it's only if I can't sleep, then I take it.
William L. England, Jr., Administrative Law Judge
I see.
Nancy Moran, Patient
And similarly, you have in your records about loxapine, which she had prescribed 5 and I had 5 pills. In times of very heavy stress like Christmas and traveling and all that, I was taking one or two a day as PRN prescribed. I was having a good period then. I was not needing to take the neuroleptic. Now when I ran out of beer that time ...
Linda Gordon, Esquire, Public Defender
Ms. Moran, just answer the questions.
William L. England, Jr., Administrative Law Judge
Now, Ms. Moran, just one other question. You said you worked in the prison system.
Nancy Moran, Patient
I have a B.A. from the University of Pennsylvania in Natural Science.
William L. England, Jr., Administrative Law Judge
Were you a paid employee of the prison system?
Nancy Moran, Patient
I started out as a CETA worker ... [change of tape]
William L. England, Jr., Administrative Law Judge
My question was, were you ever a paid employee of the ...
Nancy Moran, Patient
I was employed by the Comprehensive Education and Training program that was extant in 1980 during the Ronald Reagan Administration. It was phased out on April 1, 1981 at which point I became a volunteer for the Baltimore City Jail. I was working in the Law Library. I was the Law Library Coordinator and then I worked for Inmate Council.
William L. England, Jr., Administrative Law Judge
And when did you last work there?
Nancy Moran, Patient
Baltimore City Council ...
William L. England, Jr., Administrative Law Judge
Yes, on a regular basis. As a volunteer.
Nancy Moran, Patient
For Baltimore City Jail in 1980 and 1981. But all my people went over to the House of Correction and the Penitentiary. And Roxbury and Hagerstown and Cumberland and ECI. And the work release system and the Baltimore Pre-Release Unit and the Brockbridge, Jessup, SUI.
William L. England, Jr., Administrative Law Judge
All right. Thank you. Any follow up questions based on ...
Linda Gordon, Esquire, Public Defender
No.
William L. England, Jr., Administrative Law Judge
Any other witnesses.
Linda Gordon, Esquire, Public Defender
No.
William L. England, Jr., Administrative Law Judge
All right. Closing arguments.
Thomas Lanz, Esquire, Attorney for the Hospital
Yes, the Hospital feels that Ms. Moran should be detained from this hearing because of all the elements have been met by clear and convincing evidence. That Ms. Moran has bipolar disorder, a long history of that disorder, currently in a hypomanic state while previously being in a manic state and she still presents with psychotic symptoms as was testified by Dr. Udebuiwa, her attending psychiatrist on the Unit.
Ms. Moran presents today as being partially compliant with medication. She had been not compliant for approximately five weeks with her medications outside which led to her gradual decline in functioning as was stated by Dr. Udebiuwa. She continues to have poor hygiene, with extremely poor insight and judgment. She expressed some grandiose as well as some paranoid delusions about the healthcare system, the defense system, as was testified by Dr. Mullen, and today it is mentioned a potential killing in her neighborhood that was on her behalf, she testified to.
She remains irritable and hyperverbal. Both of her doctors have testified that there has been some mild improvement. Dr. Adebuiwa has testified that that was probably related to her being in a supervised setting for 24-hour locked care with staff who were able to manage and maintain her.
It was also testified that she does require that level of care at this time because she is not stable and requires an antipsychotic medication to help her delusions and her psychotic symptoms.
Ms. Moran does not wish to be a voluntary patient because she wants to leave. She cannot be treated in a less restrictive environment based upon her refusing medications, her poor insight and judgment.
For all these reasons, Ms. Moran meets the criteria of inpatient admission and should be retained based upon her symptoms that make her dangerous.
William L. England, Jr., Administrative Law Judge
Thank you. Ms. Gordon?
Linda Gordon, Esquire, Public Defender
I would just ask that you take into consideration Ms. Moran's testimony today that she did not barricade herself into her house and she didn't throw anything out the window except a cigarette or some ...
Nancy Moran, Patient
Trinkets, candies.
Linda Gordon, Esquire, Public Defender
Yeah, candy or keys. She didn't hurt anyone. There's no testimony that she has threatened to harm anyone or has actually harmed anyone. Or that she's harmed herself. She's not suicidal. And I don't believe that her conduct rises to the level of clear and convincing evidence of dangerousness. Thank you.
William L. England, Jr., Administrative Law Judge
Well, let me take this under advisement.
Considering all the evidence and testimony I recommend the involuntary admission of Nancy Moran.
I find that such evidence is clear and convincing that the individual has a mental disorder, that this disorder has been diagnosed as bipolar affective disorder with psychotic features. The individual is in need of institutional care and treatment based on the expert testimony which has not been refuted. But is the patient will not be compliant with the medications that are necessary to treat her mental disorder in the absence of an institutional setting as of this date.
There is little evidence that that the individual presents a danger to others. There is more evidence that she presents a danger to her own life or safety. The expert testimony is that as a manifestation of a mental disorder which is not being treated outside of the institutional setting, she was not taking care of herself properly in terms of not eating or sleeping. That she was wandering in the street. The home was infested and that she invited strangers into her house, one who was a former prisoner and at least that part was corroborated by the petitioner's own testimony that she knows a lot of former prisoners and has them come around to do things for her.
And also there is testimony that has not been refuted that another manifestation of her mental disorder is that she consumes alcohol in greater quantities when she is not compliant with medication than if she would be if when she is compliant.
So therefore I do find that the evidence is clear and convincing that she presents a danger to her own life or safety. And the individual is unwilling to be admitted to this facility. And there is no less restrictive form of detention which is available consistent with the individual welfare or safety.
Therefore, I find - I certify that all the above elements have been proved by clear and convincing evidence. Therefore, the individual shall be admitted as an involuntary patient at this facility.
If you are dissatisfied with the Administrative Law Judge's decision, you have the right to seek judicial review under Rule 7-2 of the Annotated Code of Maryland. By filing such an appeal within 30 days from the day of the certification of the appropriate court.
You also have the right to file a writ of Habeas Corpus or petition for judicial release in accordance with Maryland Health-General Code Annotated Section 10-[unintelligible].
In accordance with the Code of Maryland Regulations 10-4201.06, you shall have a subsequent hearing within a 30 day period immediately preceding each subsequent 180 days following the Administrative Law Judge's initial certification of that fact.
Thank you. That concludes this proceeding.