"Agitation must be sedated, otherwise the patient will die."
                                                                           Lewis Goldfrank, M.D.
                                                                           Director, Emergency Medicine,
                                                                           New York University Hospital
                                                                           and Bellevue

                                 Trial Memorandum
                                                    Seth Speken

Day 1 Saturday

In the afternoon of Saturday, August 21, 1993, Seth Speken, aged 23 and a pre-law college student, son of Dr. and Mrs. Ralph Speken, had a seizure and was taken from their home on Henry Hudson Parkway to the Allen Pavilion of Columbia-Presbyterian Hospital. Shortly thereafter his father, Ralph Speken, M.D., told the Emergency Room doctor that he had been prescribing Xanax for Panic Disorder for his son for over a year. He specifically told the E.R. doctor that Seth had recently been abusing the Xanax and had taken "at least 60 Xanax pills over the last 2-3 weeks. "* Dr. Speken's conversation with the E.R. doctor lasted for 10-15 minutes. Dr. Speken further told the E.R. doctor, "Xanax can be a tricky and dangerous drug to detoxify from. Please get someone right away who knows how to do this.

  Physicians' Desk Reference (P.D.R.), p. 2485 (1993), states:

                Withdrawal symptoms... have occurred following abrupt
                 discontinuance of benzodiazepines, including XANAX. 
                 The symptoms can range...to...tremors and convulsions
                 ...immediate management of withdrawal symptoms 
                 requires re-institution of treatment at doses of XANAX
                 sufficient to suppress symptoms. There have been reports
                 of failure of other benzodiazepines to fully suppress these
                 withdrawal symptoms. These failures have been attributable
                 to incomplete cross-tolerance but may also reflect the use
                 of an inadequate dosage regimen of the substituted 
                 benzodiazepine.

A review of the admission note reveals no mention of any of the information Dr. Speken
gave regarding Xanax. It appears that Seth, who was in a delirious state following hitting
his head during the seizure, must have denied the father's report. The E.R. doctors 
accepted this denial and dismissed the father's information.  The intern Dr. Berkowitz
ordered a urine Toxicology for Benzodiazepine. An appreciation of this finding should have 
changed the whole course of treatment.

Day 2 Sunday

The following afternoon, Dr. Speken said to Dr. Sagman as the latter was examining Seth, "Dr. Sagman, I have been treating Seth with Xanax. Over the last several weeks he has taken almost 70 pills. Don't you think the seizure could have been from withdrawal in the last

*The actual count was 68 pills beginning August 4.

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