4.Elizabeth A. Butler — Direct/Cross
530 linesMS. PENZA: Yes, Your Honor. I'm sorry. The government calls Elizabeth Butler.
THE COURT: Please raise your right hand.
(The witness is duly sworn/affirmed by the Court.)
THE COURT: Please be seated. And please state and spell your full name for the record.
ELIZABETH A. BUTLER: My full name is Elizabeth A. Butler, B-U-T-L-E-R.
(Continued on next page.)
(Continuing.)
E L I Z A B E T H A. B U T L E R, called as a witness by the Government, having been first duly sworn/affirmed by the Court, was examined and testified under oath as follows:
DIRECT EXAMINATION BY MS. PENZA:
MS. PENZA: Good afternoon, Mrs. Butler.
ELIZABETH A. BUTLER: Good afternoon.
MS. PENZA: Where do you currently live?
ELIZABETH A. BUTLER: Saratoga County.
MS. PENZA: How long have you lived in Saratoga County?
ELIZABETH A. BUTLER: About 35 years.
MS. PENZA: Are you familiar with a town called Clifton Park?
MS. PENZA: Approximately how far from where you live is Clifton Park, New York?
ELIZABETH A. BUTLER: About six-and-a-half miles.
MS. PENZA: Do you currently work?
MS. PENZA: Are you retired?
ELIZABETH A. BUTLER: I'm retired, yes.
MS. PENZA: What is the last place you worked before you were retired?
ELIZABETH A. BUTLER: McGinnis Women's Medical Care.
MS. PENZA: How long did you work there?
ELIZABETH A. BUTLER: I worked there for eleven years.
MS. PENZA: What did you do there?
ELIZABETH A. BUTLER: I actually had two roles at the office. I was a women's health care nurse practitioner, so I saw patients. And then I was also the office manager for eleven years.
MS. PENZA: And so you are a nurse practitioner?
MS. PENZA: Can you walk us through your educational background?
ELIZABETH A. BUTLER: Yes. I attended Ellis Hospital School of Nursing to obtain my RN. And then I continued with school through SUNY Utica Rome Institute of Technology and obtained my Bachelor's degree in nursing. And then from there I went to -- I attended and graduated from University of Pennsylvania. They had a joint program with PPFA, the Planned Parenthood Federation of America, for women's health care nurse practitioners.
MS. PENZA: Now, what is the -- what is that program that you took at UPenn, can you explain that a little bit?
ELIZABETH A. BUTLER: Yeah, it's a program for nurse practitioners -- for nurses to became nurse practitioners with the general focus in just women's health care, which was everything from menarche all the way through the life span, all the way through menopause, pregnancies. Its focus was women's health.
MS. PENZA: Now can you explain what a nurse practitioner is?
ELIZABETH A. BUTLER: Yes. A nurse practitioner is a -- we're advanced clinical practice nurses. Nurse practitioners start out as RNs and then you continue your education and your clinical skills, develop new clinical skills. It's an advanced level. It's also referred to as a mid-level practitioner. Same as a PA, but the difference between -- there are some differences between PAs and nurse practitioners, but it's on that level where we work --
THE COURT: PA is?
ELIZABETH A. BUTLER: Oh, I'm sorry, physician assistant.
ELIZABETH A. BUTLER: The main differences are that nurse practitioners can actually practice autonomously in New York State. So we can actually own our own practice. We don't have to work under the supervision of a physician, we just have to have a collaborating physician, so we can own our own office. We can, you know, run our own practice.
MS. PENZA: And why did you want to become a nurse practitioner?
ELIZABETH A. BUTLER: That's going back. I wanted to become a nurse practitioner because when I was young I really wanted to be a physician. I wanted to be a doctor and I never had the opportunity, so as an adult I went back to school and started with my RN, and then went on to be a nurse practitioner. And thought I would continue to get my Doctorate, but I was very happy doing what I was doing. I was very happy in my current job setting and I was very happy just being a nurse practitioner. I had plenty of time to spend with patients and deal with the women.
MS. PENZA: Now, where did you start working after you graduated?
ELIZABETH A. BUTLER: When I first graduated, I took a position with Dr. Grace Jorgensen at Bellevue Woman's Hospital in Niskayuna.
MS. PENZA: And how long did you work there?
ELIZABETH A. BUTLER: I worked there until Dr. Joyce -- Mary Joyce McGinnis left that practice to start her own practice and I left with her. So we both left.
MS. PENZA: And is that where you then continued to work until you retired?
ELIZABETH A. BUTLER: Yes. Yes.
MS. PENZA: Do you still do some work for McGinnis Women's Health?
MS. PENZA: What type of work do you do?
ELIZABETH A. BUTLER: Well, I volunteer my time and I will take phone calls and actually talk to them if they're having issues with management, or some issues in the office, but every month I do balance their books for them. So I do stay in contact with them.
MS. PENZA: Now, can you describe what the practice at McGinnis Women's Health was focused on?
ELIZABETH A. BUTLER: McGinnis Women's Health it's an OB/GYN office, obstetrics and gynecology, so women's health. Again, in my field where it was young women at menarche all the way through their life span. Pregnancies -- we did everything from well care for women, taking care of them through their teenage years, through their pregnancies, through menopause. We performed terminations. We did the entire scope of women's health.
MS. PENZA: And you said that you had two roles in the office.
MS. PENZA: Is that right?
MS. PENZA: Can we talk first about your role with patients and can you describe --
ELIZABETH A. BUTLER: Okay.
MS. PENZA: -- what you did in that way?
ELIZABETH A. BUTLER: With patients I did -- I did a lot. I actually would perform exams, order diagnostic testing, laboratory testing. I would diagnose patients, prescribe the right course of treatments or prescribe medications for them and see them through that. I also took care of prenatal, did prenatal care for patients. Took care of them throughout their entire pregnancies. Did menopausal care, did medical terminations, performed minor surgical procedures in the office.
MS. PENZA: And then what was -- in terms of your office manager role, what was your role in that respect?
ELIZABETH A. BUTLER: In the office manager role I pretty much ran the office. I did everything from managing the staff and overseeing the staff, payroll, monitoring expenses and supplies, handled all the patient problems or, you know, any type of conflict in the office.
MS. PENZA: Now, you mentioned terminations. Is that another word for an abortion?
MS. PENZA: And you mentioned medical abortions.
Can you just explain, just generally, what the difference is between a medical abortion and a surgical abortion?
ELIZABETH A. BUTLER: Yeah, a medical abortion is done with medications. It's done with two different types of medications that are given at 48-hour intervals.
Surgical abortion involves either a clinic setting or a hospital setting where a patient actually has to go in and be anesthetized and have a surgical procedure done to remove the pregnancy.
MS. PENZA: If someone doesn't have insurance, what is the cost difference between a medical abortion and a surgical abortion?
ELIZABETH A. BUTLER: Now, I've been retired a few years, but when I was still working, a medical termination in the office, we usually charged $750. And that covered everything, their medication, the initial ultrasound -- excuse me, the initial ultrasound they needed for dating, and it required at least three office visits. And so the 750 covered that entire procedure.
Surgical abortions that are done in the hospital setting, if we had to book a patient at the hospital to have a surgical abortion, the cost there, because of the involvement of the operating room, the recovery room and the hospital stay, it could be as high as 8,000, $10,000.
MS. PENZA: And with a medical abortion, you said that there are multiple -- multiple office visits, is that right?
MS. PENZA: And can you explain the reasoning behind the multiple office visits?
ELIZABETH A. BUTLER: Well, usually, we had a set protocol, so that when somebody called and said that they wanted a termination or said that they were pregnant and not sure what they wanted, the first appointment when they came in, we usually -- you know, we'd run a pregnancy test, sometimes an ultrasound the same day, because we needed to know whether or not they truly were pregnant, how far along they were. We needed to discuss -- we always needed to discuss, you know, what their options were with the pregnancy. Did they want to consider continuing the pregnancy and being a single parent?
In a lot of cases they might want to continue the pregnancy and put the baby up for adoption. That's always another option for them; or were they sure they wanted to terminate.
So we would do all of that in the first visit and try to get a grasp on things, but we'd never do -- we would never do the termination the first day we saw the patient just because they said they wanted one. We always had to be sure they were confident in that decision.
Appointment number two, they could come back and, you know, review all the risks and benefits again and sign paperwork saying that that's what they wanted to do. And then they would take their first dose of medication at that visit.
THE COURT: Can I just ask a question?
Where someone was unsure as to what she wanted to do, did you ever refer patients to social services organizations where they could discuss adoption or --
ELIZABETH A. BUTLER: We have --
THE COURT: -- or some other alternative than a termination or abortion?
ELIZABETH A. BUTLER: Yes. Yes. There have been cases where we have had somebody who was really unsure, and they come back for the second visit and they still show some signs that they're not really sure, then we withhold the medication. We say, you know, maybe you need to think about this some more. Maybe you should talk to somebody at the adoption tree. Maybe we should, you know, explore other options.
THE COURT: I see.
ELIZABETH A. BUTLER: And then often patients will still come back, will call and say: No, I'm sure about my decision, I really want to go through with this. But we would always refer them or withhold the medication until they were sure that's what they wanted.
THE COURT: All right, thank you.
ELIZABETH A. BUTLER: We had to -- we felt like we had to see that confidence in their decision.
BY MS. PENZA:
MS. PENZA: These back-and-forth questions that you're asking at the beginning, did you consider those pertinent to the medical treatment that you were providing to these individuals?
ELIZABETH A. BUTLER: Would you repeat that?
MS. PENZA: Yes.
This kind of -- this questioning or this dialogue that you're describing, or counseling I actually think is the word you used, that you're describing with patients who come in for a medical abortion, is that dialogue, that counseling, that conversation, do you consider that part of the medical treatment?
MS. PENZA: Why is that?
ELIZABETH A. BUTLER: Well, it's -- it's a pretty major decision to make, number one. You know, there's such a psychological impact with it. And we just really feel that they really need to know what they're -- what the outcome of their decision is, you know. There's always those pros and cons with everything you do. You know, you can't -- we don't want them second-guessing what they're doing.
So it's -- it's also very important in that counseling session to -- I'm trying to -- I'm trying to psychologically make sure they're prepared for that.
MS. PENZA: Now, you mentioned that the second visit, that's when you would actually -- they would actually get the first dose of the medication?
MS. PENZA: And do they actually have to take the medication in front of a nurse?
ELIZABETH A. BUTLER: Yes. Yes, they actually have to take it in front of the practitioner, the first dose of medication. The first dose of medication is a very expensive dose of medication, number one. And number two, we want to see them take it without hesitation. We want to see that they've actually taken the pills and swallowed them. It's not the type of medication you want to prescribe to somebody and let them just go home and take it. You don't want it in anybody else's hands.
MS. PENZA: Why is that?
ELIZABETH A. BUTLER: Well, the original name of the drug was RU-486 and it does have its consequence. It interrupts the pregnancy is what it does, so letting that medication fall into the wrong hands of somebody else who is pregnant, or somebody who is not pregnant, you know, it -- the side effects or the consequences of the medication are not good.
Once they take that medication, they have to proceed. They sign a paper saying they know they have to proceed with the next dose.
MS. PENZA: Okay.
Now, when the medical abortion -- is there -- are there risks to that, are there medical risks?
ELIZABETH A. BUTLER: Yeah, there are. There are risks to the medical abortion. They can -- we go over all those risks with them. The major risk is bleeding or hemorrhaging, so we go over the signs and symptoms of hemorrhaging.
We usually make sure that they know that they can call the office twenty-four hours a day and get a practitioner to talk to them or talk them through to see if they need to proceed and go to the hospital. There is always that chance that they would hemorrhage and need to go to a hospital.
There is severe pain involved with the medical termination, but we always warn them. And I used to tell my patients that it would be like the worst period they could ever have in their life; that they could be curled up in a ball in pain; that they're going to bleed a lot; that it's going to be -- I don't know how graphic you want me to get, but --
MS. PENZA: I don't think we need to be more graphic.
But it's a painful --
ELIZABETH A. BUTLER: It can be a painful procedure.
MS. PENZA: Do you actually prescribe painkillers?
ELIZABETH A. BUTLER: Yes, we do. We offer them to patients. Some patients will refuse them, and then we have them take high doses of Motrin. Other patients, they know their pain threshold is lower and they need them, yeah.
MS. PENZA: And do you talk to patients about having somebody with them?
MS. PENZA: Can you explain that?
ELIZABETH A. BUTLER: Yes. Because of the potential side effects of the medication and because it can come on suddenly and they can start bleeding very heavy and passing large clots and things, they may get lightheaded, dizzy, we always ask that they have another person with them that knows what's going on because if, you know, any of these things happen, they could potentially stand up, fall. It's just not safe to be by yourself during that timeframe.
MS. PENZA: And just one more question.
The questions that you -- would sometimes people have -- would patients sometimes have someone else with them when they would be talking to a practitioner?
ELIZABETH A. BUTLER: Yeah. Yes, they would. Not always, it's not required. It's something that some patients come in and bring somebody for moral support, or just for that extra emotional support, and that was up to them.
MS. PENZA: But it wouldn't be -- is it fair to say it wouldn't uncommon or unusual --
MS. PENZA: -- that someone else would be in the room when there is a back-and-forth --
MS. PENZA: -- When there's this back-and-forth?
ELIZABETH A. BUTLER: No, not uncommon at all.
MS. PENZA: Now, I want to talk more -- in terms of your general, the forms that would be used at McGinnis -- McGinnis Women's Health?
ELIZABETH A. BUTLER: McGinnis Women's Medical Care, yeah.
MS. PENZA: Now, did you help actually design any forms in your role --
MS. PENZA: -- at McGinnis?
ELIZABETH A. BUTLER: I did.
MS. PENZA: Can you explain?
ELIZABETH A. BUTLER: I actually designed the annual health form and another form that was called The Problem Visit.
Well, I also did registration forms, but they were revised forms from our previous practice, but I did do the annual exam form and The Problem Visit form, which The Problem Visit form was for anything that was not an annual visit.
MS. PENZA: Your Honor, may I have the ELMO just for the witness, please?
THE COURT: Go ahead.
BY MS. PENZA:
MS. PENZA: Can you see this form in front of you, Mrs. Butler?
MS. PENZA: And is this the annual form that you helped design?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And can you just explain -- and this one is filled out, but without going into any of the details about this particular patient, can you just explain the form and what the importance of the various sections are?
ELIZABETH A. BUTLER: Yeah, we divided the form -- I say we, I did consult with the doctors that I worked with, with what we needed on the form. We divided the form up so that we could cover every aspect that we needed to properly diagnose the patient, treat the patient or, you know, maintain their health.
Do you want to know about each section?
MS. PENZA: Well, let me just -- maybe we can just take them in quadrants.
ELIZABETH A. BUTLER: Okay.
MS. PENZA: I guess it's three main areas. So let's start just with this medical history/family history. There is a question about illnesses and surgeries.
How is that pertinent to your treatment of a patient?
ELIZABETH A. BUTLER: Well, you know, if a patient comes in and has scars on their body anywhere, of course we want to know what they had done, what type of surgery they've had done. In the GYN setting, there could be certain surgeries that may be related to female health or developmental -- or the development of the female organs. But surgeries and illnesses, you really need to know what a patient has had in the past or currently has because any type of medication can affect current or previous medical history.
MS. PENZA: And then, just moving down, you ask about medications?
ELIZABETH A. BUTLER: Uh-hum.
MS. PENZA: That's also --
ELIZABETH A. BUTLER: Also the same thing because if we need to prescribe something, we need to know what they're currently on so we don't cause any interactions between medications.
MS. PENZA: And then there is a series of check boxes?
MS. PENZA: Smoking?
MS. PENZA: What's E --
ELIZABETH A. BUTLER: These are habits. ETOH is alcohol use.
MS. PENZA: Ah; what does that stand for? That's an abbreviation for --
ELIZABETH A. BUTLER: Yes, that's an abbreviation for that. But all of those things are habits that can be changed. It tells us whether or not they have a healthy lifestyle, whether or not there's other things to -- you know, somebody who checks off alcohol, you know, then we have to investigate how much they're using every day.
MS. PENZA: There is a box here for abuse, is that right?
MS. PENZA: What is -- how is that pertinent to your medical treatment of someone?
ELIZABETH A. BUTLER: Well, we always screen to make sure that somebody doesn't have a history of any type of abuse, whether it's physical abuse, sexual abuse, whether it's verbal, physical, whatever, you know, any type of abuse because that may require additional counseling. We may refer them for more counseling. We may -- it can effect their long-term healthcare or their lifestyles.
MS. PENZA: And then the next -- the next part says sexually active?
ELIZABETH A. BUTLER: Uh-hum.
MS. PENZA: And then there is a -- there is a yes or no check box. What is the import of that?
ELIZABETH A. BUTLER: Well, whether or not somebody is sexually active certainly does pertain a lot to what we're doing in the office, as far as prescribing and contraceptive care and counseling. How -- whether or not they're sexually active then it leads on to, you know, how many partners they have had, how old they were when they became sexually active.
All of those things are pertinent because we need to know do we need to talk about contraception; do we need to talk about, you know, if they've been sexually active a long time and had, you know, 10, 20 partners; we need to talk about their risk for STDs, whether or not they're at risk for sexually transmitted diseases, HIV. You know, it all comes into the same category, and they need to be counseled with all of that.
It also tells us that -- you know, sometimes we might see -- we might see somebody who has been sexually active for a number of years, and when you look at different things like ages or whatever, you have to start -- you start questioning -- okay, if somebody comes in and they're twenty years old, but they became sexually active at thirteen, then you go back to the previous question of was there any abuse. You know, it kind of -- it all ties in together with their psychological and their physical health.
MS. PENZA: Okay.
ELIZABETH A. BUTLER: And that's why those questions are on there and that's why we elaborate and put how many partners and how old they were when they became sexually active.
MS. PENZA: And would that have been a routine question that would be asked, how long you've been --
MS. PENZA: -- with the same partner?
MS. PENZA: And that's for the reasons --
MS. PENZA: -- that you've described?
MS. PENZA: Your Honor, may I approach the witness?
THE COURT: Yes, you may.
BY MS. PENZA:
MS. PENZA: Mrs. Butler, I'm handing you what are marked for identification purposes as Government Exhibit 539 and Government Exhibit 540. I am just going to ask you to take a look at those.
ELIZABETH A. BUTLER: (Witness complies.) Okay.
MS. PENZA: Have you had a chance to look at those?
ELIZABETH A. BUTLER: Yeah. I haven't read every page.
MS. PENZA: But are you familiar with those documents?
MS. PENZA: And is Government Exhibit 539 a copy of Camila
medical records from McGinnis Women's Medical Care?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And is Government Exhibit 540 a copy --
(Sidebar held.)
(Continued on following page.)
(In open court - jury present.)
EXAMINATION CONTINUING BY MS. PENZA:
MS. PENZA: And, Mrs. Butler, turning to Government Exhibit 540, is this a copy of a woman named Daniela's medical records?
MS. PENZA: And Government Exhibit 540 and Government Exhibit 539, are those both accompanied by a certificate of authenticity from Lori Clark?
MS. PENZA: Do you know Lori Clark?
ELIZABETH A. BUTLER: Yes, I do.
MS. PENZA: Who is Lori Clark?
ELIZABETH A. BUTLER: Lori Clark is the manager that I trained to replace me when I retired.
MS. PENZA: And --
ELIZABETH A. BUTLER: And she is still currently the manager.
MS. PENZA: And these records are certified by her?
MS. PENZA: And you've now reviewed them?
MS. PENZA: And they appear to be the records of these individuals?
ELIZABETH A. BUTLER: Yes, they do.
MS. PENZA: I am just going to show you the same --
MS. PENZA: Still just for the witness, Your Honor.
THE COURT: Yes.
MS. PENZA: Thank you.
BY MS. PENZA:
MS. PENZA: Showing you the notation in the upper left quadrant, without saying what the actual notation is on Government Exhibit 539-18 --
ELIZABETH A. BUTLER: Uh-hum.
MS. PENZA: -- is there -- is there a notation in that box under sexually active?
If you turn to Government Exhibit 539 Page 18, it should be on your screen as well.
THE COURT: Is your screen working?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: Do you see where I'm pointing?
ELIZABETH A. BUTLER: Yes, there is.
MS. PENZA: And is that notation of the same type that you already described?
MS. PENZA: And is that a notation that would have been pertinent to Camila's medical treatment at that time?
ELIZABETH A. BUTLER: Yes, it would.
MS. PENZA: Your Honor, at this time the Government offers Government Exhibit 540 and Government Exhibit 539 into evidence.
MS. GERAGOS: Over our previous argument, Judge, we object, but we understand.
THE COURT: Very well. Over objection, Government Exhibits 539 and 540 are received into evidence.
(Government's Exhibits 539 and 540 were received in evidence.)
MS. PENZA: Thank you, Your Honor. It just may take me a moment to shuffle the two versions that I have.
THE COURT: Yes, all right.
(Continuing on the following page.)
(Continuing)
MS. PENZA: Looking a Government's Exhibit 539, page 1 and page 2, this is the appointment history for Camila; is that right?
ELIZABETH A. BUTLER: Yes, it is.
THE COURT: Did you want this...?
MS. PENZA: Oh, yes, Your Honor. May I publish this to the jury. This is a redacted version.
THE COURT: Okay.
(Exhibit published.)
THE COURT: All right. Go ahead.
MS. PENZA: So Mrs. Butler.
MS. PENZA: Is this the appointment history for Camila?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: This and the page following?
MS. PENZA: And looking at this page, there are various notes.
Do you see that?
ELIZABETH A. BUTLER: Yes, I do.
MS. PENZA: How do the notes get entered on to the appointment history?
ELIZABETH A. BUTLER: When somebody called to make an appointment and it's put in the computer system, under that particular patient's name, the provider name, all of that stuff, this is computer-generated. This is the information that's been in the computer system. So you can just go in and print out an appointment history for any particular patient in the practice and it will come out and it will tell when their appointment was scheduled, who it was scheduled with, what the appointment was for.
MS. PENZA: Okay.
ELIZABETH A. BUTLER: And then where it says notes, the receptionist usually types in anything that's kind of unusual for the appointment scheduling.
For instance -- do you want me to say?
MS. PENZA: Sure. Go ahead.
ELIZABETH A. BUTLER: Okay. For instance, on this particular one, most or all of these appointments were made, not by the patient themselves. And that's kind of unusual. Usually we try to encourage the patients to make their own appointments.
In this case, all of these appointments look like they say: Friend Pam made the appointment.
MS. PENZA: And that's true of every single one of these appointments?
MS. PENZA: And Pam, friend Pam, friend Pam?
ELIZABETH A. BUTLER: Yes. Yes, on both pages.
MS. PENZA: And then I think there -- would there often be multiple registration forms in the same set of medical records?
MS. PENZA: Why is that?
ELIZABETH A. BUTLER: Because they're typically updated every year.
MS. PENZA: Okay.
MS. PENZA: I'm showing you Government Exhibit 539-11.
(Exhibit published.)
MS. PENZA: Is this a registration form?
MS. PENZA: Okay. And is this the typical registration form from McGinnis Women's?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And is one of the things that is asked for an emergency contact?
MS. PENZA: And here, who is Camila's emergency contact?
ELIZABETH A. BUTLER: Pamela Cafritz.
MS. PENZA: It has a phone number for her as well?
ELIZABETH A. BUTLER: Yes, it does.
MS. PENZA: And the date of this was 5/14/08?
MS. PENZA: This is -- do you know -- are you familiar with this form?
ELIZABETH A. BUTLER: Yes, I am.
MS. PENZA: Can you explain what this form is?
ELIZABETH A. BUTLER: Okay. This form, it's actually a version of a older form that we had, that we used to use. We don't use this one too much anymore, but it's basically a problem visit, or a follow-up visit.
MS. PENZA: Okay. And is this -- would this have been the form that corresponds to Camila's pregnancy confirmation?
ELIZABETH A. BUTLER: Yes, this would have been her first visit to discuss possible termination.
MS. PENZA: And it says: Moved here from Mexico three years ago. Status: Finished school in Mexico?
MS. PENZA: And it says: No medical insurance?
ELIZABETH A. BUTLER: Right. No medical insurance.
MS. PENZA: And it says: Pregnancy confirmation, wishes to terminate?
ELIZABETH A. BUTLER: Yes, it does.
MS. PENZA: Patient was told in Mexico she was unable to conceive?
MS. PENZA: Showing you Government Exhibit 539, page 18. This is the one I showed you before.
MS. PENZA: This is annual gynecological exam form?
MS. PENZA: And this is a form for Camila?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: Okay. And it's filled out on -- but are the dates on the top right sometimes -- are there sometimes issues with the dates on the top?
ELIZABETH A. BUTLER: Yes, there are. Yes.
MS. PENZA: Can you explain?
ELIZABETH A. BUTLER: Okay. What happens sometimes -- and it looks like this form is one of them. Charts are prepared ahead of time when patients are coming. So the nurses will pull the charts sometimes, you know, 4 or 5 days ahead of time, sometimes the day before, and they get the charts ready and they get them ready by filling in the patient's name, filling in any medical allergies, things that don't typically change, and they date the form.
So this one looks like it was dated, and the appointment was probably changed. And then -- so when they went to prep the chart for the visit, again, instead of replacing that page, they just changed -- the nurses changed the date on it.
Does that make sense? They just changed the date on it?
So if you look in the computer system, you know, sometimes it will show in the computer system on the appointment history, it will show up as an appointment that was either like 10/12 -- 10/12/10 was probably rescheduled, no show. It was probably something where the patient didn't come in.
MS. PENZA: Okay. And so if we look at the very bottom, there's a date here.
Is that an accurate date?
ELIZABETH A. BUTLER: That's the date that I would consider accurate, yes.
MS. PENZA: Okay.
ELIZABETH A. BUTLER: That's the date that that particular nurse practitioner saw that patient.
MS. PENZA: And if we look briefly at the appointment history for Camila.
(Exhibit published.)
MS. PENZA: Fair to say that --
ELIZABETH A. BUTLER: Right.
MS. PENZA: -- that was -- there had been like an appointment of some sort of 10 --
ELIZABETH A. BUTLER: 10/12. And it would have been an annual, which is that particular form.
And then if you look past 30 minutes, it says no show. The patient didn't show up that day. So that's why the date was crossed off and this one was reused.
MS. PENZA: This one, okay.
So just looking at the top left, it says Camila. And it has a date of birth of March 1st, 1990?
MS. PENZA: She lists an allergy to hydrocodone?
ELIZABETH A. BUTLER: Hydrocodone, yes.
MS. PENZA: Is that a painkiller?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And then if we look in her medical history, family history, it says: Appendectomy, age 16; is that right?
MS. PENZA: Okay. And then she lists medications. One of them is Seasonique. Do you know what that is?
ELIZABETH A. BUTLER: That's a birth control pill.
MS. PENZA: Do you know what the other things that are on here are?
ELIZABETH A. BUTLER: Yes. Yes. She was taking Seasonique, which is a birth control pill. CA, is calcium, magnesium, vitamin C, kelp and fennel. Those are all vitamins and herbs or supplements.
MS. PENZA: And then under sexually active, yes is checked?
MS. PENZA: And then underneath that, it says five years with partner?
MS. PENZA: And that would been in response to the sexually active question?
ELIZABETH A. BUTLER: Yes. She would have been asked how old she -- or she was when she became sexually active or how long she's been sexually active and how many partners she's been with.
MS. PENZA: Okay. And so this would indicate that she had been for five years with the same partner?
ELIZABETH A. BUTLER: Same partner.
MS. PENZA: And was that important, given the fact that she is here for an annual exam?
MS. PENZA: And she's on -- does -- she appears to be on birth control pills?
MS. PENZA: If somebody has multiple partners, is that something where -- and is on birth control pills, would you want to discuss other options for protection from sexually transmitted diseases?
ELIZABETH A. BUTLER: Yes. We would still discuss the use of condoms to prevent sexually transmitted diseases, yes.
MS. PENZA: Okay.
MS. PENZA: Turning to Government Exhibit 540, 540-1.
(Exhibit published.)
MS. PENZA: We said this is Daniela's medical records; is that right?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And she only had three appointments at McGinnis?
MS. PENZA: And would these have been the three appointments that correspond to a medical termination?
ELIZABETH A. BUTLER: Yes, the first one, a confirmation. The second one, the medication was given. And then the third one was just follow-up to make sure that everything turned out okay.
MS. PENZA: Showing you Government Exhibit 540-3.
(Exhibit published.)
MS. PENZA: Is this the initial visit form for Daniela?
MS. PENZA: Age 20?
MS. PENZA: Date of birth 10/26/85?
ELIZABETH A. BUTLER: '85, yes.
MS. PENZA: And the date of this initial visit is October 3rd, 2006?
MS. PENZA: And name and address of nearest relative. And it lists Pamela Cafritz, 3 Flintlock Lane, Clifton Park, New York?
MS. PENZA: This is 540-7.
(Exhibit published.)
MS. PENZA: And this is a problem visit form; is that right?
MS. PENZA: It says: Is not currently sexually active but plans to see boyfriend soon?
MS. PENZA: And claims to have Mexican OCs. Is that oral contraceptives?
ELIZABETH A. BUTLER: Yes, it is.
MS. PENZA: And turning to page 549.
(Exhibit published.)
MS. PENZA: It says: Unintended pregnancy. Desires medical, if possible. That is a medical abortion?
MS. PENZA: State -- well, can you read what it says?
ELIZABETH A. BUTLER: Then it says: States has support of friend of partner. Has desire for pregnancy.
MS. PENZA: Has no desire?
ELIZABETH A. BUTLER: Has no desire. Has no desire. That's what that symbol means. Has no desire for pregnancy at this time.
MS. PENZA: And then what does it say?
Lives in --
ELIZABETH A. BUTLER: Lives in Mexico. Maybe I can see better up there.
Lives in lives in Mexico. Visiting her -- okay. I'm sorry. Can I just repeat that?
MS. PENZA: Sure.
ELIZABETH A. BUTLER: Okay. Has no desire for pregnancy at this time. Lives in Mexico. Visiting here times two to three months. Considering college.
MS. PENZA: Does it say: Considering college in U.S.A.?
ELIZABETH A. BUTLER: In U.S.A., yes.
THE COURT: I am sorry. What was the date of that particular page?
MS. PENZA: 10/3/08.
THE COURT: All right. Thank you.
BY MS. PENZA:
MS. PENZA: Mrs. Butler, were you familiar with Pam Cafritz?
MS. PENZA: How did you become familiar with Pam Cafritz?
ELIZABETH A. BUTLER: I became familiar with Pam because of a phone call made to the office.
MS. PENZA: Do you remember when that was?
ELIZABETH A. BUTLER: I don't remember the exact date. It was a couple of days after one of the girls had came in for termination.
MS. PENZA: And I'm going to show you what's in evidence, Government Exhibit 549-68.
And -69.
(Exhibit published.)
MS. PENZA: Are these notes from a call with Pam Cafritz?
ELIZABETH A. BUTLER: Yes. This is a telephone sheet. The receptionist took the phone call prior to me speaking to Pam.
Pam called the office upset.
THE COURT: All right.
MS. PENZA: Sorry. I was using the wrong one. I'm switching over to the --
THE COURT: Are you inquiring about a phone conversation?
MS. PENZA: I was just going to first get the date, for her.
THE COURT: All right. Go ahead.
MS. PENZA: I'm sorry, Your Honor. I have to switch back to the other set of -- I started using the wrong set the documents again.
THE COURT: That is fine.
(Pause in the proceedings.)
MS. PENZA: So just showing you the date.
(Exhibit published.)
BY MS. PENZA:
MS. PENZA: Do you remember that it was on 5/21/08?
MS. PENZA: That there was a phone call?
ELIZABETH A. BUTLER: There was a phone call, yes.
MS. PENZA: Okay. And then there's more back and forth on 5/22/08?
MS. PENZA: We are going to talk about the conversation, Your Honor, so now may be an appropriate time.
THE COURT: All right.
Members of the Jury, the witness is about to give testimony about a conversation she had with Pam Cafritz. You may only consider this testimony as it relates to the means and methods of the charged criminal enterprise. You are not to consider this testimony for the truth of the matters asserted in the conversation.
MS. PENZA: Thank you, Your Honor.
THE COURT: You are welcome.
BY MS. PENZA:
MS. PENZA: So how did you come to have a conversation with Pam Cafritz?
ELIZABETH A. BUTLER: It started with Pam calling the office and called the office very upset, talked to the receptionist and demanded to talk to Dr. Mary Jo McGinnis. She wanted to talk to Dr. McGinnis and she didn't want to settle for anything else. Didn't want to talk to the nurse practitioner.
So, in our office, I was the office manager and the policy was Dr. McGinnis didn't handle anything unless she was directly involved in it, and my job as office manager was to handle these kinds of problems and smooth over phone calls with either irate patients or a lot of times husbands, whatever. And so the phone call was passed from Dr. McGinnis to myself.
And I returned Pam's phone call and we didn't touch base the first time I called her. And then I believe it was the next day again -- I don't have it in front of me, but I believe it was the next day again that I tried to call her and I did reach her.
MS. PENZA: And what happened?
ELIZABETH A. BUTLER: Pam was -- Pam was very upset. She was pretty much yelling and saying that -- she was actually accusing our office of breaking HIPAA laws, violating HIPAA laws.
THE COURT: What are HIPAA laws?
ELIZABETH A. BUTLER: HIPAA laws, Health Information Privacy Act. It's to protect the patient's privacy and not releasing personal health information.
ELIZABETH A. BUTLER: So, she was -- she was --
MS. PENZA: What was she saying specifically?
ELIZABETH A. BUTLER: Specifically, she got into -- and it really doesn't have a whole lot to do with the health information privacy laws. She got into that the nurse practitioner, Judy, who saw this patient, she felt that Judy was accusing the girls or putting information into the girls' head that there was some type of abuse or something going on, because Judy had questioned about nonconsensual sex. She had questioned them about abuse; if there was any potential abuse or anything going on because of this unintended pregnancy.
And Pam was upset about that and felt that these ideas were being put into their heads.
MS. PENZA: And how did you respond? How did you handle the situation?
ELIZABETH A. BUTLER: Well, there was no -- when I took the phone call, I made it perfectly clear to Pam that she could vent all she wanted and that she could, you know, just speak her peace, tell me what she needed to tell me, but I couldn't speak to her directly about any specific information related to the patient because there was no signed consent in the chart.
If a patient comes in and they give us permission to talk to an outside person, they actually have to sign for that. They have to sign a form telling us that we can talk to -- like if they wanted to us talk to Pam, they could sign the form saying that we could talk to Pam about whatever. We could talk to her about birth control pills, but not about pregnancy.
We could talk to her about her sexually transmitted disease, but not the number of partners. You know, we -- we make them get very specific about what we can and can't say.
In this case, there was no signed form in the chart. So I told Pam I couldn't speak anything specific to that particular patient, but I could tell her that these questions are questions that we ask everybody. These are general questions to protect somebody's health and to protect their privacy and that person. And it helped us to care for the person.
I basically couldn't tell her much of anything.
THE COURT: Which patient was she calling about, if you recall?
ELIZABETH A. BUTLER: No. I have to be honest, I do not remember which -- I believe it was Camila, but I'm not sure.
MS. PENZA: And did she provide you any information about her role with --
ELIZABETH A. BUTLER: Yes. She told me that she was responsible. She had been responsible for this -- this girl for the last two years, and that it was her responsibility. And I still explained to her that I still couldn't release the information. It didn't matter.
MS. PENZA: Your Honor, no further questions.
THE COURT: Why don't we take our break and then we will have cross-examination.
MR. AGNIFILO: Very good.
THE COURT: All rise for the jury.
COURT CLERK: All rise.
(Jury exits.)
(In open court; outside the presence of the jury.)
THE COURT: Ms. Butler, you can step down now. Please don't discuss your testimony with anyone.
We are going to take a ten-minute break.
ELIZABETH A. BUTLER: Okay.
THE COURT: Thank you.
About how much?
MS. GERAGOS: A few questions.
THE COURT: Okay.
All right. We will take a ten-minute break.
(Recess taken.)
(Continued on following page.)
(In open court; outside the presence of the jury.)
THE COURT: Let's bring in the witness.
MS. PENZA: We're going to do our absolute best but we have two more out of town witnesses who we believe will be very short and so we are wondering, Your Honor, if necessary, if we can, could stay an extra 15 minutes or so.
THE COURT: Let's check with the jury.
Just tell the jury we have exactly that.
MS. PENZA: Thank you, Your Honor.
THE COURT: Mr. Geragos, are you going to be questioning?
MS. GERAGOS: Yes.
(Pause.)
THE COURT: Yes. The word back from the jury is, yes, only 15 minutes.
MS. PENZA: Yes. Yes, Your Honor.
THE COURT: And I second that motion.
All right. So let's bring in the jury, please.
(Jury enters.)
THE COURT: All right. Please be seated, everyone.
Ms. Geragos, you may cross-examine.
The witness is reminded that she is still under oath.
MS. GERAGOS: Thank you, Your Honor.
CROSS-EXAMINATION BY MS. GERAGOS:
MS. GERAGOS: Good afternoon, Mrs. Butler. My name is Teny Geragos and I represent Keith Raniere. Nice to meet you.
ELIZABETH A. BUTLER: Nice to meet you.
MS. GERAGOS: So when we left off with Ms. Penza, you spoke about a conversation you had with Ms. Cafritz on I think May 21, 2008, is that correct?
MS. GERAGOS: I'm going to show you what's in evidence as Government Exhibit 539-22. I'll zoom in. This is written on May 19, 2008, correct?
MS. GERAGOS: And it states here, she's not a smoker, correct?
MS. GERAGOS: There's no alcohol or drug abuse?
MS. GERAGOS: There's no emotional problems with Camila, correct?
MS. GERAGOS: No domestic violence?
MS. GERAGOS: And no STD or HIV risk, correct?
MS. GERAGOS: And that she's sure of her decision to terminate the pregnancy, right?
MS. GERAGOS: And that's two days before your conversation with Ms. Cafritz?
MS. GERAGOS: Okay. I am showing you what's in evidence as Government Exhibit 539-24. And that's May 14, 2008, correct?
ELIZABETH A. BUTLER: Yes, it is.
MS. GERAGOS: And similar to the one we saw a few days later, it indicates she's not a smoker, correct?
ELIZABETH A. BUTLER: Correct, yes. Correct.
MS. GERAGOS: No alcohol or drug abuse?
MS. GERAGOS: No emotional problems?
MS. GERAGOS: No domestic violence?
MS. GERAGOS: And she's not at risk for STD or HIV, correct?
MS. GERAGOS: And that she wishes to terminate?
MS. GERAGOS: And that's about a week before your conversation, right?
MS. GERAGOS: Because you stated on direct examination that you have about, was it four meetings with somebody who wishes to terminate or two visits with somebody who wishes to terminate?
ELIZABETH A. BUTLER: Three.
MS. GERAGOS: Three meetings. And at the first meeting, you have to make sure they understand what they're doing, right?
MS. GERAGOS: That they're sure of their decision and you never give them the medical termination on the first visit, correct?
ELIZABETH A. BUTLER: Correct.
MS. GERAGOS: I'm just going to turn the page, the second page of what we were looking at, Government Exhibit 539-25.
This is written in doctor handwriting, it's a little bit difficult to read, but does it say: States significant other aware of pregnancy, denies nonconsensual?
MS. GERAGOS: Is that what that says: Would like to terminate the pregnancy?
MS. GERAGOS: Options reviewed at length?
MS. GERAGOS: Correct? And that's on 5/14, right?
MS. GERAGOS: All right. So that same day, May 14, 2008, you filled out this form, the patient history form, right?
MS. GERAGOS: Or someone filled it out. Probably not you. And it says, What is your present method of birth control, right?
MS. GERAGOS: And it says None there?
ELIZABETH A. BUTLER: It says, None.
MS. GERAGOS: An that's on May 14, 2008?
MS. GERAGOS: Okay. I believe we talked a little bit about with Ms. Penza 539-18. This form, annual gynecological exam, that says, Five years with partner. Correct?
ELIZABETH A. BUTLER: Correct.
MS. GERAGOS: You didn't make this notation, right? This was Ms. Fuller?
ELIZABETH A. BUTLER: Fuller, yes.
MS. GERAGOS: So when you said the questions that would have been asked or may have been asked as to whether she was sexually active, you didn't ask them, right?
ELIZABETH A. BUTLER: No, I did not.
MS. GERAGOS: One last question. We spoke a little bit about the annual gynecological exam sheet. And can you just one more time tell us what the point of this sheet is that you made with the quadrants, this one?
ELIZABETH A. BUTLER: The point of the sheet is to be as concise as possible and to be as accurate as possible with gathering the information from the patient that we would need to diagnose or treat any potential problems, to prescribe and to handle any health issues that they may have.
MS. GERAGOS: Because you want the patient to be truthful with you and honest, right?
ELIZABETH A. BUTLER: We want them to be, yes.
MS. GERAGOS: Okay. So I'm just going to show you Government Exhibit 549, page 9, and this part about problems. And this was Daniela's annual gynecological exam, correct?
MS. GERAGOS: And here, can you just read one more time what it says here? Lives, what does that say?
ELIZABETH A. BUTLER: Lives in Mexico. Visiting here times two to three months. Considering college in USA.
MS. GERAGOS: And can you just read the date of that?
ELIZABETH A. BUTLER: 10/3/2006.
MS. GERAGOS: Okay. And then here, what does it say? One lifetime partner?
ELIZABETH A. BUTLER: One lifetime partner.
MS. GERAGOS: Under whether or not it says she's sexually active?
MS. GERAGOS: No further questions, Your Honor.
MS. PENZA: No redirect.
THE COURT: Very well. The witness is excused. You may stand down.
ELIZABETH A. BUTLER: Thank you.
THE COURT: You're very welcome.
(Witness excused.)
THE COURT: All right. The government may call its next witness.