The physician who treated the late Kara Philbrick-Lenker for years spent hours Friday testifying about her case, her medical charts and her overall care, as part of Dr. Chris Christensen's negligent homicide trial.
Dr. Eric Ravitz with Missoula’s Blue Mountain Clinic said Lenker was a “complex” patient, with her treatment made more difficult by her tendency to self-medicate with alcohol — drinking up to a half-gallon of vodka per day. She was agoraphobic, meaning she feared leaving her home; she suffered from extreme social anxiety and insomnia, which can be a symptom of depression; she had neurodermatitis, with itchy skin making her scratch enough to give her lesions.
She also had gastroesophageal reflux disease, also known as heartburn, and “classic radial nerve palsy” in one wrist from drinking and falling asleep in a strange position, which creates a dramatic form of a pinched nerve. And, she suffered from chronic pain.
“She was intelligent, with a lot of mental health and physical health issues, and they were prolonged, going on for a long time,” Ravitz told the jury. “That combination of self-treatment — good, solid knowledge of medicine, if you will — made her very complicated. It created that therapeutic tension of, ‘This is what I want. This is what I think will work for me.’”
What she wanted, he said, was 100 milligrams of methadone to replace the fentanyl patch he prescribed, along with a variety of other medications to treat her various maladies. But Ravitz warned her that not only would he not prescribe that amount of methadone, she needed to quit drinking.
“With her and methadone, knowing how she can binge-drink and fall off the wagon, I didn’t want to have any risk of methadone becoming something catastrophic,” he said, adding that he feared she would accidentally overdose, which she had done prior to becoming his patient.
Instead, she told him she was going to seek a second opinion, and she visited with Christensen. She walked out with a prescription for 100 milligrams of methadone, and three days later, she was dead from an overdose from a combination of prescription drugs.
Christensen is charged with two counts of negligent homicide, nine counts of criminal endangerment, and 11 counts of distribution of dangerous drugs. One of the homicide charges is based on Lenker’s overdose.
County Attorney Bill Fulbright gave Ravitz a copy of Christensen’s medical charts, which he said didn’t include that standard “SOAP” documentation — Subjective, Objective, Assessment, Plan.
The subjective portion is the person’s medical history and why the person is consulting a doctor. The objective is basic findings, such as blood pressure and other physical attributes. The assessment entails what the physician makes of the situation and a potential diagnosis. The plan portion lays out what treatment will occur.
“The SOAP notes are important to guide you, to follow up and create a relationship so you can accurately navigate the issue,” Ravitz said, holding Christensen’s medical notes, then looking at the jury. “I saw no evidence of that.”
He also voiced concerns over Christensen’s prescribing the methadone, in which he ordered her to start with 30 milligrams of methadone, and gradually increase it to 90 milligrams within six days. Ravitz said pain management typically tries to involve the lowest does possible.
“I find that very troubling,” he said.
On cross-examination, Attorney Josh Van de Wetering questioned Ravitz about working with insurance companies and his attitude about prescribing opioids. Ravitz said he had no qualms about it in certain cases, but not at the amounts Lenker requested.
Van de Wetering then gave Ravitz copies of his own charts for Lenker, noting that on her second visit the dictation machine Ravitz used didn’t work and all that was on the chart was a brief handwritten note about their meeting. He also noted that Ravitz didn’t include Lenker’s previous medical records in her file.
Eventually, Judge Jeffrey Langton warned Van de Wetering about his lengthy questioning of Ravitz’s records and the relevance to the case. Van de Wetering responded that he was doing so because Christensen’s lack of lengthy notes “seems to be relevant to the negligent homicide case.”
“I believe the state is trying to suggest Dr. Christensen’s charting somehow demonstrates he’s guilty of negligent homicide,” Van de Wetering said. “I’m trying to explore various charting and how accurate it may be.”
The trial continues next week.