1 1 State of Ohio, ) SS: 2 County of Cuyahoga. ) 3 - - - 4 IN THE COURT OF COMMON PLEAS 5 - - - 6 AARON HALEVI, aka, RONI ) HALEVI, et al., ) 7 ) Plaintiffs, ) 8 ) v. ) Case No. 370550 9 ) Judge Stuart Friedman THE CLEVELAND CLINIC ) 10 FOUNDATION, et al., ) ) 11 Defendants. ) 12 - - - 13 THE DEPOSITION OF KEITH B. ARMITAGE, M.D. 14 FEBRUARY 24, 2000 15 - - - 16 The deposition of KEITH B. ARMITAGE, M.D., a 17 witness, called for examination by the Plaintiffs, 18 under the Ohio Rules of Civil Procedure, taken before 19 me, Janet M. Hoffmaster, Registered Professional 20 Reporter and Notary Public in and for the State of 21 Ohio, pursuant to notice, at University Hospitals, 22 Lakeside Building, Cleveland, Ohio, commencing at 2:05 23 p.m., the day and date above set forth. 24 25 - - - 2 1 APPEARANCES: 2 On behalf of the Plaintiffs: 3 RUBIN GUTTMAN, ESQ. Rubin Guttman Co., L.P.A. 4 55 Public Square, Suite 1860 Cleveland, Ohio 44113 5 (216) 696-4006 6 7 On behalf of the Defendants: 8 BEVERLY SANDACZ, ESQ. Reminger & Reminger 9 The 113 St. Clair Building Cleveland, Ohio 44114 10 (216) 687-1311 11 12 13 - - - 14 15 16 17 18 19 20 21 22 23 24 25 3 1 INDEX 2 PAGES 3 CROSS-EXAMINATION BY 4 MR. GUTTMAN 4 5 6 7 - - - 8 9 10 11 OBJECTIONS BY 12 MS. SANDACZ 14, 16, 18, 19, 22, 23, 13 25(2), 27(2), 28, 29, 34, 35, 36, 37, 38, 40(2), 41, 14 46, 47, 57, 59 15 16 - - - 17 18 19 20 21 22 23 24 25 4 1 KEITH B. ARMITAGE, M.D. 2 a witness, called for examination by the Plaintiffs, 3 under the Rules, having been first duly sworn, as 4 hereinafter certified, deposed and said as follows: 5 CROSS-EXAMINATION 6 BY MR. GUTTMAN: 7 Q. Doctor, would you state your full name for the 8 record, please? 9 A. Keith B. Armitage. 10 Q. Doctor, where are you currently employed? 11 A. Case Western Reserve University, University 12 Hospitals of Cleveland. 13 Q. And what position do you hold? 14 A. Associate Professor of Medicine at Case Western 15 Reserve University and vice-chair for education in the 16 Department of Medicine. 17 Q. Do you have any particular areas of specialty? 18 A. Infectious diseases. 19 Q. Have you done any particular fellowships or 20 anything of that nature in infectious disease? 21 A. Right, infectious diseases is a fellowship 22 that's two or three years following internal medicine, 23 so I did infectious disease fellowship following three 24 years of internal medicine. 25 Q. Where did you do that? 5 1 A. University Hospitals. 2 Q. How long have you been at UH? 3 A. I came here as an intern in 1986. I have been 4 on the staff since 1992. 5 Q. Now, we are here regarding litigation filed on 6 behalf of Aaron Halevi against the Cleveland Clinic and 7 it's my understanding you've rendered certain opinions 8 in that case. 9 A. Nods. Yes. 10 Q. Please answer verbally. 11 A. Yes. 12 Q. Before we get to that, what have you read before 13 coming here today? 14 A. I've read what I believe is the complete medical 15 record of Mr. Halevi at the Cleveland Clinic and I've 16 read the deposition of Dr. Cosgrove, which I guess is 17 the first deposition of Dr. Cosgrove, and then I read a 18 deposition of Dr. Longworth. I've read the report of 19 Dr. Gordon and the report of Dr. Best, and just today, 20 I'm not sure if I had the other report, there's a 21 report from a CT surgeon in Florida. 22 Q. Dr. Bronstein? 23 A. I read that one today. 24 Q. Have you read Hofstetter's report? 25 A. No. 6 1 Q. Have you read any other deposition transcripts? 2 A. No. 3 Q. You say you've read the whole record. Does that 4 mean you've gone through the nurses notes page by page? 5 A. I read every single progress note by all the 6 physicians and I believe I read through the nurses 7 notes. Sometimes the nurses notes are repetitive and I 8 won't claim to have read every word. 9 Q. You said you've read all of the progress notes? 10 A. Yes. 11 Q. Does that include the radiology notes and 12 everybody, all the specialties? 13 A. The radiologist doesn't write progress notes. 14 They write reports and I've looked at those, correct. 15 Q. Now, I believe you have testified on behalf of 16 the Cleveland Clinic or one of its physicians in the 17 past? 18 A. Correct. 19 Q. On how many occasions? 20 A. I believe twice. 21 Q. When was that? 22 A. I believe it was one -- it was when PIE still 23 existed and when it was Jacobson, Maynard, Tuschman. I 24 think that's the only time I testified in court on 25 behalf of the Cleveland Clinic. 7 1 Q. Have you given depositions on behalf of the 2 Cleveland Clinic on more than that one occasion? 3 A. Other than that one, I can't think of any, but 4 there might be one other. I'm just blanking out. 5 Q. How many occasions in your career have you 6 testified in a medical malpractice case? 7 A. I think probably five times. 8 Q. Any of those on behalf of plaintiffs? 9 A. Yes. 10 Q. When was that? 11 A. It was in Chicago two years ago. 12 Q. Do you recall who the counsel was for the 13 plaintiff? 14 A. No. I know the firm. 15 Q. What was the firm? 16 A. Goldberg, Weisman, Cairo. 17 Q. There's a firm in Cleveland named Goldberg, 18 Weisman. 19 A. Yes, I actually have testified also for the 20 plaintiff in Cleveland in a case involving the 21 Cleveland Clinic. 22 Q. So you've testified against the Cleveland Clinic 23 as well? 24 A. Correct. Those are the only two times I've 25 testified for the plaintiff. 8 1 Q. So total testimony would be seven times? 2 A. Five. 3 Q. Five including the two for the plaintiff. 4 A. Correct. 5 Q. Those are the times you have testified. 6 Have you rendered opinions in other cases? 7 A. Yes. 8 Q. In how many cases have you rendered opinions? 9 A. In the last five years probably -- I probably 10 looked at records in maybe 40 cases and rendered 11 opinions in 20 cases or given some sort of a report or 12 at least been named as an expert. 13 Q. Somewhere between 20 and 40 cases? 14 A. Sometimes I look at cases and then I give an 15 opinion and I'm no longer involved because it's not 16 helpful, but I probably have written reports or been 17 named as an expert in the last five years probably -- 18 between 15 or 20 times. 19 Q. And what percentage of those were plaintiff, 20 what percentage defense? 21 A. 40 percent plaintiff and 60 percent defense. 22 Q. Now, I think we marked this as Exhibit 89, just 23 handing you what I believe we marked as Exhibit 89. 24 MS. SANDACZ: What do you 25 mean 89? 9 1 MR. GUTTMAN: Plaintiff's 2 Exhibit 89, going sequentially with all 3 the exhibits we've used in all the 4 depositions. 5 MS. SANDACZ: I just didn't 6 know. Go ahead. 7 BY MR. GUTTMAN: 8 Q. Can you identify that, please? 9 A. Yes, this is a report that I wrote or a letter I 10 wrote regarding the case of Halevi versus the Cleveland 11 Clinic. 12 Q. Doctor, I apologize, that is not Exhibit 89. 13 Probably Exhibit 90, but Exhibit 89 I'll show you now. 14 Is that a true and accurate copy of your CV? 15 A. Yes, it is. 16 Q. And Exhibit 90 which is the report dated 17 November 11, 1999, is that a true and accurate copy of 18 the report you've rendered in this case? 19 A. Yes, it is. 20 Q. Are there any opinions that you've rendered in 21 this case which are not embodied in that report? 22 A. No. 23 Q. By the way, do you have any personal or 24 professional relationship with Dr. Cosgrove? 25 A. I've never laid eyes on him or spoken to him. 10 1 Q. How about Dr. Longworth? 2 A. I've spoken to him, you know, a patient that was 3 admitted here who he had followed, the Cleveland Clinic 4 got called for information once as an infectious 5 disease colleague. And all the infectious disease 6 doctors in town have joint conferences together and so 7 I've seen him at that occasionally. We are both very 8 busy so there are more times than not when one of the 9 two of us can't go, but we overlap on occasion. 10 Q. Have you spoken to him about this case? 11 A. No. 12 Q. Doctor, in reviewing your CV you have written a 13 variety of articles over time, some chapters in books, 14 any of them related to the infectious disease issues 15 affecting this case? 16 A. Not specifically to this type of infection, no. 17 Q. In fact, most of your work has been with the 18 elderly? 19 A. Yes. My research was with the elderly and most 20 of my articles and presentations have dealt with either 21 pneumonia or gastroenteritis. 22 Q. Just to make sure we are clear, Klebsiella 23 pneumoniae, not pneumonia, right? 24 A. You know, either one is acceptable as far as I 25 can tell. 11 1 Q. I guess what I was asking you, your work has 2 been on pneumonia, not on the Klebsiella bacteria? 3 A. I haven't done any specific research on 4 Klebsiella pneumoniae. I'm familiar with it. 5 Q. Have you done any research work on nosocomial 6 infections? 7 A. I have been involved in clinical trials here in 8 antibiotics in nosocomial infections, and the care 9 path, I'm in charge of the care path for pneumonia 10 here, and we have a separate part of our care path for 11 nosocomial pneumonia, but other than that I haven't 12 done research on nosocomial infections. 13 Q. Now, when you say you're involved in the care 14 path, if Roni Halevi had been a patient at University 15 Hospitals would he have been under your care or someone 16 from your department then? 17 A. No. I think had he been here I'm sure someone 18 from my department would have seen him as a consultant, 19 but he wouldn't have fallen into the care path that I'm 20 in charge of, no. 21 Q. Most of that deals with the elderly? 22 A. No, with people who acquire pneumonia in the 23 hospital, but he wasn't someone who was identified as 24 having pneumonia. 25 Q. So since it wasn't a hospital-acquired 12 1 pneumonia, just a hospital-acquired infection, it 2 wouldn't have been your area? 3 A. Right. 4 Q. Have you done any work on the issue of 5 translocation of gut bacteria? 6 A. No. 7 Q. One final question on your CV, you made 8 reference to an article or part of a chapter in a 9 practical guide to infectious disease, has that 10 actually been published? 11 A. I think that's still in press. I'm not sure 12 that has been published. 13 Q. Didn't say. Frankly just couldn't find it 14 anywhere. 15 A. I have that one. Actually I have it at home. 16 It has been published. They are actually coming out 17 with a second edition. 18 Q. Do you know who it is distributed by? 19 A. Raven, I think, isn't that what I put there? 20 Q. You did say Raven, but we couldn't find it. 21 A. Ed Hook is the editor and his daughter-in-law is 22 editing the second edition, so I just got a letter from 23 her asking me to submit revisions. 24 Q. The Library of Congress had no records. I'm not 25 doubting you. 13 1 A. I can bring it in and show it to you. I think I 2 have it at home, not my office, because I'm -- 3 Q. Working on it, sure. 4 In the course of your practice have you had any 5 experience treating mitral valve repair patients who 6 suffered a lacerated liver? 7 A. Well, in anticipation of a question like this I 8 thought have I seen patients who had lacerated livers 9 as part of cardiothoracic surgery, and I can't recall 10 that I have. I have seen patients who had lacerated 11 livers from trauma, but I don't recall seeing a patient 12 with a lacerated liver from cardiothoracic surgery as a 13 consultant. 14 Q. You mentioned you've seen patients suffer a 15 lacerated liver as a result of trauma? 16 A. Correct. 17 Q. Would you analogize what Mr. Halevi experienced 18 as a trauma case? 19 A. Not necessarily. 20 Q. What would be the difference in your mind? 21 A. In a trauma case there's much more likely to be 22 a vascular insult. 23 Q. Hepatic portal? 24 A. Yes, blood supplies, and I think in this case 25 there was some injury to the dome or the surface of the 14 1 liver, but nothing that affected a major artery or 2 vein. 3 Q. Now, how do you know what portion of Mr. 4 Halevi's liver was hurt? 5 A. From reading the progress notes and from reading 6 Dr. Cosgrove's deposition. 7 Q. You weren't able to tell how his liver -- the 8 nature of the liver injuries from the chart, were you? 9 MS. SANDACZ: Objection. 10 Go ahead. 11 A. There wasn't an operative note, but I think 12 there was progress notes that referred to this liver 13 injury, progress notes that referred to the fact that 14 it happened and how it happened, and I did read 15 Dr. Cosgrove's deposition. 16 Q. And from the chart were you able to ascertain in 17 your mind the mechanism that caused the injury? 18 A. No. 19 Q. Were you able to ascertain whether either the 20 parietal or visceral pleura were torn? 21 A. Not specifically, no. 22 Q. What about the peritoneum? 23 A. In what way? 24 Q. Somehow in the mechanism of tearing the liver -- 25 A. The peritoneum is a space. 15 1 Q. Peritoneal lining. 2 A. Peritoneal lining? 3 Q. Sorry. 4 A. It wasn't mentioned there was any injury. 5 Q. You indicate in your report that Mr. Halevi 6 underwent mitral valve repair on September 9th. During 7 the immediate postoperative period he returned to the 8 OR for bleeding due to laceration of the liver. He 9 then did well for several days. 10 A. Right. 11 Q. Based on your examination of the chart weren't 12 there several indications that in fact he might be 13 becoming septic? 14 A. Well, he had some low grade fever which is not 15 uncommon in a post-op patient like this. He had a mild 16 elevation in his white count, but they were mobilizing 17 him, he was getting physical therapy, they were talking 18 about discharge. 19 Q. What about his liver function tests, did you 20 look at them? 21 A. Yes. 22 Q. And would you agree that he was 23 hypobilirubinemic? 24 A. Or hyper? He had an elevation of his bilirubin 25 in the post-op period which is something you can see 16 1 from blood being absorbed, not necessarily -- 2 Q. How about hypoalbuminemia? 3 A. More of a problem later. 4 Q. Let's take a look. I would like to refer you to 5 what we call page 450 of the record which would be the 6 blood work-ups for September 10th at 2:00 a.m. 7 MS. SANDACZ: 09-10? 8 MR. GUTTMAN: Yes. 9 A. Lab reports, okay. 10 Q. Do you see where the albumin report is reported 11 as being a 2? 12 A. I see an albumin done at 2:00 a.m. 13 Q. 2:00 a.m., but it is also a reading of 2. 14 A. Right, I see, but I was saying the 10th, okay. 15 Q. Wouldn't that be rather low? 16 A. That's low. It is not unusual in a sick post-op 17 patient who is in a catabolic -- 18 Q. When you say a sick post-op patient, basically 19 he was as low risk a patient as you get up until the 20 liver injury occurred; isn't that correct? 21 MS. SANDACZ: Objection. 22 Go ahead. 23 A. I'm not sure. 24 Q. We know aside from the valve problem he was 25 reasonably healthy. 17 1 A. Correct. 2 Q. He was 37 years old? 3 A. Correct. 4 Q. Did he have any other unusual risk factors that 5 you're aware of? 6 A. He certainly wasn't someone who you would 7 identify as increased risk. 8 Q. And would the albumin reading indicate a liver 9 problem to you? 10 A. The people who have end stage liver disease who 11 have a synthetic dysfunction can have low albumin. In 12 a patient who has tons of IV fluids, between his first 13 surgery and second surgery they gave him lots of IV 14 fluids, a dilutional effect, he lost a lot of blood, 15 I'm not sure that in that setting that that low albumin 16 reflected a liver synthetic function. 17 Albumin has a relatively long half-life, so this 18 was less than 24 hours after his liver laceration. I 19 don't think that could account for the low albumin at 20 that point. 21 Q. The bleeding from his liver and the fluids that 22 were pushed to try to keep up his pressure during the 23 intersurgical period could be responsible for it? 24 A. Correct, but not any liver problem per se. 25 Q. And you would agree, though, if he had not 18 1 experienced the liver laceration they wouldn't have had 2 to push all those fluids and he wouldn't have been 3 bleeding? 4 A. Well, they push the fluids for post-op 5 hypotension which was ultimately believed to have been 6 from bleeding from the liver. 7 Q. And was ultimately proved to be that, wasn't it? 8 A. Correct. 9 Q. Would you agree that the liver laceration 10 constitutes a serious operative complication? 11 A. I don't know how you determine serious. I know 12 that the complication from the liver laceration was 13 bleeding and the bleeding was something that was easily 14 addressed by taking him to the OR, and I don't think 15 there's any permanent damage related to the injury to 16 the liver. 17 Q. But the need to put him under anesthesia a 18 second time in a relatively short period of time did 19 create an additional risk for infection; did it not? 20 MS. SANDACZ: Objection. 21 A. I'm not sure if that kind of risk has been 22 quantified. 23 Q. Would you agree that the abdominal surgery is 24 associated with a greater risk of infection than the 25 cardiovascular surgery? 19 1 MS. SANDACZ: Objection. 2 A. There are different types of abdominal surgery. 3 There's surgery on the bowel which is a different 4 category of surgery than surgery on the chest, but I 5 don't know that surgery to repair a liver laceration is 6 associated with more infection versus a bowel resection 7 or bowel problem. 8 Q. What about handling the bowel, wouldn't that 9 increase the risk of infection? 10 A. I don't know. 11 Q. Are you familiar with those articles that talk 12 about handling the bowel as creating an increased risk 13 of gut translocation? 14 A. I don't have firsthand knowledge. 15 Q. What about the fact that Mr. Halevi went into 16 afib and had to be cardioverted twice in the first 17 three days postoperative, do you consider that a 18 complication? 19 A. That's a very common post cardiac surgery 20 phenomenon and it's something I see a lot or see 21 patients who have that problem. In preparation for 22 this deposition I looked at Dr. Cosgrove's deposition. 23 I believe he said a quarter of his patients have 24 post-op afib. 25 In my experience as a consultant on post CT 20 1 surgery patients I'm not consulted for that problem, 2 but in my experience I've seen a lot of patients who 3 have that. That's not an unusual post-op event. 4 Q. In an otherwise young, healthy patient? 5 A. Sure. 6 Q. And would you characterize it as a complication? 7 A. No. 8 Q. What would you characterize it as? 9 A. As an event. 10 Q. All right. An official event? 11 A. Post-op afib is just a very common problem in 12 cardiac surgery, non cardiac surgery, and I wouldn't 13 term it a complication. You could call it a side 14 effect. 15 Q. Is it associated at all with a compromise of the 16 immune system? 17 A. Post-op afib, no. 18 Q. Associated at all with infection? 19 A. No. 20 Q. Doctor, as a preliminary matter, in your report 21 you indicate that you expressed your opinions, in the 22 last paragraph, in terms of a degree of medical 23 certainty, that is, postoperative sepsis syndrome 24 resulted from an infected hematoma in the right pleural 25 space. 21 1 First of all, would it be your opinion then that 2 the hematoma in turn created the bloodstream infection 3 or the bacteremia? 4 A. It is all speculation, but if you look at a case 5 from 25,000 feet, the only objective data we have is 6 his blood cultures are positive and that the hematoma 7 was positive, so either the bacteria in the blood 8 seeded the hematoma, or the hematoma led to the seeding 9 in the blood, but there's no way to know for sure which 10 one was related. I think the reason I mention that in 11 my report, I did not think that what happened below the 12 diaphragm was responsible for the infection. 13 Q. You say what happened below the diaphragm wasn't 14 responsible for the infection, we will get into the 15 details in a moment. 16 You said you did not find any evidence in the 17 medical record to demonstrate beyond a reasonable 18 degree of medical certainty direct or indirect 19 involvement of the liver laceration and the Klebsiella 20 infection. 21 Now, reasonable degree of medical certainty, 22 what about reasonable medical probability, isn't it 23 probable that the need to do the second surgery and all 24 that went with it did have involvement in the 25 Klebsiella infection? 22 1 MS. SANDACZ: Objection. 2 A. I just look at the facts of the case, that 3 postoperatively patients have effusions and hematomas. 4 He had a sepsis syndrome with Klebsiella in his blood 5 and in his hematoma or effusion, and that's all you can 6 say. Those are the only facts in the case in terms of 7 determining where the infection came from. 8 Q. When you say where the infection came from, what 9 do you mean by that phrase, where did the Klebsiella 10 come from? 11 A. I was referring to the source in the patient, 12 that's referring to the hematoma. 13 You mean in general? 14 Q. Yes. I mean where did the Klebsiella that 15 created the sepsis come from? 16 A. Klebsiella is a common bacteria found in 17 hospitalized patients, common cause of line infection, 18 post-op pneumonia, so it could have come from the 19 hospital environment, he could have gotten colonized 20 with Klebsiella. 21 Q. It's a nosocomial infection, correct? 22 A. It can be. 23 Q. Isn't it generally thought to be nosocomial and 24 not community acquired? 25 A. Well, Klebsiella pneumoniae causes community- 23 1 acquired pneumonia, particularly in a certain subset of 2 patients as a classic presentation. It also can be 3 nosocomial. 4 Q. In what subset of patients does it present as 5 community acquired? 6 A. People with ethanol abuse. 7 Q. Mr. Halevi was not one of those as far as we 8 know. 9 A. No. 10 Q. It is more probable than not it was hospital 11 acquired in his case? 12 A. Correct. 13 Q. Now, are you aware that from 1988 to '95 the 14 Clinic experienced a doubling in the rate of Klebsiella 15 pneumoniae infections in its cardiac intensive care 16 unit? 17 MS. SANDACZ: Objection. 18 A. No. 19 Q. Does that affect your analysis in this case? 20 A. No. 21 Q. Now, we were talking about the hematoma, the 22 infected hematoma. 23 Do you have an opinion as to whether Roni Halevi 24 got inoculated with the Klebsiella? 25 A. No. 24 1 Q. What is the incubation period for a Klebsiella 2 infection? 3 A. That's an interesting question. 4 Q. Excuse me, so the record is clear, when I say 5 Klebsiella, I'm referring to the Klebsiella pneumoniae 6 that was Ronnie Halevi's sepsis. 7 A. I don't think of it like an incubation period 8 like you get exposed to someone with the measles and 9 two days later you get sick. 10 I would think in a bacteria like this that 11 ultimately led to sepsis that it was probably acquired 12 in the 24 to 48 hours before he manifested signs of 13 sepsis. 14 Q. Now, at that point in time both his abdomen and 15 his chest were closed already from the second surgery, 16 correct? 17 A. Correct. 18 Q. Do you feel that the bacteria was there prior to 19 closure? 20 A. No. There's a lot of ways bacteria can get in 21 places. People have central lines, they can get in 22 from the skin via a central line, they can get there 23 from the lung route, you can have a line infection or a 24 pneumonia or a urinary tract infection that isn't 25 really clinically significant and then you've seeded 25 1 the blood. There's a lot of ways. 2 Q. If the instrument that -- whatever it was that 3 lacerated the liver, also lacerated the diaphragm and 4 came in contact with the colon, would that not have 5 provided a vehicle for migration of Klebsiella from the 6 colonic mucosa up into the pleural space? 7 MS. SANDACZ: Objection as 8 to contact with the colon. I don't know 9 what that means. 10 A. I was not aware that happened in this case. I 11 think if you perforated the colon, then I think that 12 would make it a likely scenario that you're going to 13 have bacteria around. I think just brushing the colon 14 wouldn't make me think that it was -- that was a source 15 versus other sources, especially this organism. 16 Q. What about the manipulation of the colon in the 17 course of examining it for damage in a setting where 18 there's a tear or laceration of the diaphragm? 19 MS. SANDACZ: Objection. 20 Go ahead. 21 A. I wouldn't change my opinion. 22 Q. Would you term the Klebsiella infection a 23 complication of the laparotomy? 24 A. No. 25 Q. So your position is it's just completely 26 1 independent? 2 A. Correct. 3 Q. What about the hypotension which he experienced 4 secondary to the liver injury, is that associated with 5 an increased risk of infection? 6 A. Having a -- being hypo -- 7 Q. Bleeding internally. 8 A. In general, yes. 9 Q. And -- 10 A. I'm not saying it was in this case, but as a 11 general statement. 12 Q. How can you distinguish things that are 13 associated with being a risk factor for infection in 14 general and in this case? 15 A. Well, in this case he didn't manifest signs of 16 infection or sepsis until five days after his 17 hypotensive episode. If someone is hypotensive, you 18 injure your bowel or something, you get an ischemic 19 bowel that's not going to wait five days to show 20 itself. That's going to be an immediate problem, so 21 the fact that he really didn't show signs of sepsis or 22 infection for five days after he was hypotensive and 23 required fluid resuscitation makes me think that it 24 isn't related. 25 Q. Weren't all the factors of that day, September 27 1 9th, in terms of bleeding, the second surgery, the 2 anesthesia, aren't all those stressors which 3 compromises the immune system's ability to fight the 4 infection? 5 MS. SANDACZ: Objection. 6 A. Whether they are or not he had five days of 7 relative stability to recover. 8 Q. Now, reopening the chest twice in a few hours 9 and then I believe it was done again a day or so later, 10 isn't that associated with increased pleural effusion? 11 A. I'm not saying it is not. I'm just not aware of 12 that literature. 13 Q. You're not aware of literature that surgical 14 incisions in the pleural area are associated with 15 increased pleural effusion? 16 MS. SANDACZ: Objection. 17 A. I know patients that have cardiac surgery 18 whether valve or CABG frequently have effusions. As a 19 matter of fact, it seems like the majority of the 20 patients will have some sort of effusion and so whether 21 you have a bigger effusion or longer lasting effusion, 22 if you go in more than once, I don't know. It could be 23 possible. I just don't know. 24 Q. Do you have any opinion by the way as to whether 25 Mr. Halevi's lung was injured during the mitral valve 28 1 repair surgery? 2 A. I have no opinion. 3 Q. Would you agree that the lung injury constituted 4 trauma? 5 MS. SANDACZ: Objection. 6 Go ahead. 7 A. I wasn't aware there was a lung injury. 8 Q. I'm sorry, I misspoke. I meant the liver 9 injury. 10 MS. SANDACZ: Can you repeat 11 the question? 12 BY MR. GUTTMAN: 13 Q. Would you agree that the liver injury 14 constituted trauma? 15 A. I guess I'm not sure what you mean by the word 16 trauma. We think of trauma, I think of trauma as 17 someone being shot or hit by a car. I think it is 18 clear he had an injury to the liver, but I'm not sure 19 whether the term trauma is significant. 20 Q. It certainly wasn't an intended injury as far as 21 we know. 22 A. Correct. 23 Q. And there were wounds to the liver in at least 24 two places that we know about, correct? 25 A. Correct. 29 1 Q. And those wounds remained open and bleeding for 2 a period of around five, six hours? 3 A. Correct. 4 Q. And wouldn't that constitute a trauma which 5 would be associated with an increased risk of 6 infection? 7 MS. SANDACZ: Objection. 8 Asked and answered. Go ahead. 9 A. Again, I'm not sure what the word trauma means. 10 I think -- yes. 11 Q. By the way, do you have any opinions as to 12 whether the pleural effusion in Mr. Halevi's case was 13 transudate or exudate? 14 A. I don't recall seeing the numbers. I could look 15 at the record. It's relatively easy to tell based upon 16 the chemistries and the fluid. I think when you have a 17 bloody effusion it's generally going to be exudative. 18 Not always, but generally. 19 Q. Now, when they finally did the laparotomy they 20 removed apparently a liter, liter and a half of I 21 believe what's described as black blood. 22 Would it have been the practice in your hospital 23 under those conditions to culture that blood? 24 A. I think it's something that comes into the 25 clinical judgment of the surgeon. This is a pretty 30 1 acute event. There weren't signs or symptoms of 2 infection. I don't think there's any evidence of any 3 other internal injuries, so in general, infectious 4 disease guys, we like everything cultured all the time. 5 I'm saying that tongue in cheek. General surgeons only 6 culture things when they think there's infection or 7 something associated with infection. 8 I think when you have post-op bleeding, the 9 reason you operate is to control the bleeding, not 10 because you suspect infection. 11 Q. We talked a moment ago about Ron Halevi's post 12 surgical serum albumin of 2. Would that make him more 13 vulnerable to infection? 14 A. Again, if you take all patients that have low 15 serum albumins you could associate that with increased 16 risk. It is notable that within a few days his albumin 17 increased to 2.8 which again to me indicates that his 18 liver was functioning rather robustly. 19 Q. Well, increased to 2.8 and fell off to 1.6 20 A. When he got septic, that was due to sepsis, not 21 due to anything else, but the fact that his albumin 22 increased in a few days is a good sign. 23 Q. The 2.8 is still low; is it not? 24 A. That's still low. 25 Q. A level that you would expect to be at following 31 1 cardiac surgery? 2 A. I honestly don't know. 3 Q. What about time, length of time in surgery, does 4 it place a patient at greater risk for infection? 5 A. I think there's data for some surgeries that the 6 longer you are there is a risk. 7 Q. In this case the liver injury substantially 8 prolonged his time in surgery between the two 9 surgeries; did it not? 10 A. Yes, I don't know if the data is from the time 11 of the first surgery or not. I'm not sure how to 12 answer the question. 13 Q. What about emergency surgery, isn't that 14 associated with a greater risk of infection than 15 nonemergent surgery? 16 A. As a general statement I believe that's true. 17 Q. There was emergency surgery to repair the liver, 18 wasn't there? 19 A. Correct. 20 Q. It was true in this particular case, too, not 21 just generally, correct? 22 A. Correct. Although he didn't get infected for 23 five days later, so I'm not sure if we can say that 24 there's a direct connection there. 25 Q. But it is possible in your mind? 32 1 A. Well, I know there's an association between 2 emergent surgery in general. I'm not saying there's an 3 association in this case, so I guess I wasn't 4 understanding your previous question. 5 Just to clarify, I'm not saying there's a 6 connection in this case. 7 Q. I just want to make sure I'm clear about 8 something. Is it your testimony that from the time of 9 inoculation to the time somebody would become septic 10 from a Klebsiella pneumoniae infection is only a day 11 and a half, two days? 12 A. It's always something to speculate about, when 13 someone first got inoculated, and then the bacteria, 14 but I would expect an aggressive bacteria like this 15 that ultimately causes severe sepsis syndrome to 16 manifest itself very quickly. 17 Bacterial infections, serious bacterial 18 infections don't hide. They either get better or they 19 progress very rapidly into a sepsis syndrome like he 20 had and they don't -- they are not quiescent. 21 Q. If that's so, let's go back to the lab values we 22 were looking at a moment ago. You made mention of the 23 fact that it was significant to you that the albumin 24 had increased from 2.0 on the 10th to 2.8 on the 15th. 25 A. On the 14th, yes. 33 1 Q. If the bacteria were acting -- if the Klebsiella 2 were acting as you suggest, shouldn't his liver values 3 have not been getting better at that point? 4 A. As a matter of fact I would turn it around the 5 other way, the fact that he increases his albumin 6 during that five-day period indicates he wasn't 7 fighting infection. When you're fighting infection you 8 stop making albumin and the albumin you have you chew 9 up for energy, you break it down. And I've used the 10 terms catabolic and anabolic, they're opposite terms. 11 During those fives days he is anabolic, his 12 liver is synthesizing proteins. As soon as he got 13 septic on the 15th, pretty dramatic, 2.0 to 1.8, 14 probably part of it was dilution. When you're septic 15 your capillaries can be leaking, but your liver stops 16 making albumin. The albumin you have you sacrifice for 17 energy in order to fight infection. 18 Q. He both got inoculated and got fully septic on 19 the same day you're suggesting? 20 A. I said 24 to 48 hours, probably on the 15th. 21 Obviously you start with a small number of bacteria and 22 then they reach a critical mass to cause a sepsis 23 syndrome. There has to be some timeline. And just to 24 finish, when there's a small number of bacteria, as 25 they are dividing for the first few hours there's not 34 1 enough to cause inflammation and shut down albumin 2 creation. 3 Q. If in fact he got inoculated somewhere in the 24 4 to 48 hours, if in fact his liver had not been 5 lacerated, he is supposed to have been discharged in 6 five days, so he would have been gone before he ever 7 got inoculated? 8 A. He could have been worse, got septic outside the 9 hospital and not received all the critical care he got. 10 You could speculate either way. 11 Q. Okay. You would agree his hospital stay was 12 prolonged by the liver laceration? 13 MS. SANDACZ: Objection. 14 A. It appeared he was getting better so I believe 15 in the deposition Dr. Cosgrove said he might go home in 16 five days, and it might have been. It seemed as though 17 he was getting better the 14th, 15th, talking about 18 discharge, going to the Omni Hotel. There's a note 19 there about what kind of follow-up he would get from 20 the hotel. 21 So had he not gotten septic I think he would 22 have gone home near or at his targeted time. 23 Q. Now, prior to the second surgery while Mr. 24 Halevi was bleeding did he go into shock? 25 A. I don't know if he ever reached what we would 35 1 call shock. He was hypotensive and he required a lot 2 of fluids and blood, and I believe his blood pressure 3 was at a level you might consider shock. Shock is sort 4 of a clinical -- 5 Q. What about his arterial hematocrit and 6 hemoglobin -- 7 A. They dropped quite a bit. 8 Q. 44 and 14 something? 9 A. They dropped quite a lot. 10 Q. Would that be an indication of shock? 11 MS. SANDACZ: Objection. 12 A. Just having a low hematocrit is part of the 13 definition of shock. It is really profusion, blood 14 pressure, peripheral profusion. 15 Q. They were pushing a fair amount of fluid? 16 A. Correct. 17 Q. Would you define his condition as close to 18 shock, in shock? 19 A. I would say the reason that they went back in 20 the evening of the surgery is because they were worried 21 about him going into shock, if not being on the 22 borderline. 23 Q. In fact, if he had gone down to 4.0, that can be 24 fatal, can't it? 25 MS. SANDACZ: 4.0 what? 36 1 Objection. Hemoglobin? 2 MR. GUTTMAN: Yes. 3 A. I've seen patients much lower. It kind of 4 depends how fast you get there, how healthy you are, et 5 cetera. 6 Q. You've seen patients much lower than 4.0? 7 A. Not in this country very often where there's a 8 lot of medical care. I've seen patients 2.0 and 3.0. 9 In my CV I obviously spent time in Africa. 10 Q. A lot of different environmental factors there? 11 A. Yes. 12 Q. That hypotension placed Roni Halevi at greater 13 risk for acquiring postoperative infection? 14 A. I would say in general hypotension may be 15 associated with increased risk. Again, I think in his 16 case since he didn't show signs of infection for five 17 days it is not clear that it did. 18 Q. What about the blood in the peritoneum, wouldn't 19 that create -- doesn't that potentiate infection, too? 20 A. Having a hematoma can be a site for infection. 21 Again, I'm not -- I'm relatively convinced in this case 22 that the blood in the peritoneum didn't have anything 23 to do with what happened later. 24 Q. Even if it would have migrated via a hole in the 25 diaphragm? 37 1 A. We know that post CT surgery patients have blood 2 in their pleural space and have fluid in their pleural 3 space anyway. I don't think we need to invoke that as 4 part of the pathogenesis. 5 Q. Need to invoke it or is it a probable 6 occurrence? 7 A. It seemed far-fetched to me. 8 Q. Why would that be if in fact you do have a 9 laceration or a puncture, whatever you want to call it, 10 an opening in the diaphragm, why is that far-fetched? 11 A. The diaphragm is a muscle that probably seals 12 itself off as soon as -- if you poke a tube through it, 13 it is going to immediately seal itself off. And again, 14 I've seen patients that had intraperitoneum bleeding or 15 intraabdominal bleeding and it is not usual to have the 16 blood, you know, migrate through. 17 Q. If in fact the lacerations of the liver and 18 diaphragm were done with the chest tubes or chest tube, 19 that means it would have been in place for a matter of 20 five, six hours, something on that order, correct? 21 A. Yes. 22 Q. Wouldn't that make it more likely that the blood 23 did in fact migrate? 24 MS. SANDACZ: Objection. 25 Go ahead. 38 1 A. I don't think the blood would migrate. I don't 2 know that he had a laceration of the diaphragm. I 3 suppose it's possible. 4 Q. Based upon the review of the chart do you know 5 of any other way that the liver sustained the wounds it 6 sustained? 7 A. I'm not an expert in that, but from what I 8 understand it probably can't injure the liver without 9 going through the diaphragm. I believe that's the 10 case. 11 Q. I'm just wondering if you guys have something 12 new. 13 So then just to make sure I'm clear, given the 14 probable existence of a pathway from the abdominal 15 space into the pleural space through the diaphragm, why 16 is it so unlikely in your mind that the blood from the 17 abdominal space migrated, or at least the bacteria in 18 it anyway? 19 MS. SANDACZ: Objection as 20 to form. 21 Go ahead. 22 A. Well, if the tube is going through the 23 diaphragm, which it appears that it might have in this 24 case, and the diaphragm is a pretty strong muscle, it's 25 going to seal around the tube. When the tube is taken 39 1 out it is going to seal off, but I think more 2 importantly he recovered completely without ever having 3 any infection evacuated from his abdomen, without ever 4 having an abscess in his abdomen, and I think his 5 clinical course is such that he didn't have 6 intraabdominal infection. He got better when they got 7 all the material out of his pleural space. That's when 8 they isolated the organism. 9 Very early on in his course when he was so ill 10 the consultants were concerned that he could have 11 intraabdominal infection and there was thought about 12 having the operation. The fact he got better without 13 any drain or major operation indicates to me there 14 wasn't intraabdominal infection. 15 Q. He had stopped bleeding in the abdomen once they 16 repaired the liver. He was continuing to experience 17 effusion in the pleural space? 18 A. In my experience if there was Klebsiella 19 pneumoniae sitting in the body where they had the 20 blood, that's what transmigrated through the hole in 21 the diaphragm, that infection would have been in the 22 abdomen, too. It wouldn't have been just limited to 23 the pleural space. 24 Q. So your testimony is it would either have been 25 both or it didn't come from the abdomen? 40 1 A. I think if that blood in the abdomen was 2 infected, even though they removed a lot of it, there 3 still would have been an infection left behind in the 4 abdominal space and his clinical course would have been 5 different. He would have had intraabdominal infection 6 and not just pleural infection. 7 Q. Well, they did try to clean out the abdomen, 8 didn't they? 9 A. They took the blood out. The other part of the 10 story, as I've said several times, he didn't manifest 11 overt signs of infection for five or six days. So 12 again, I think if they left behind infection in the 13 abdomen he would have formed an abscess, he would have 14 gotten sick, there would have been findings there 15 quicker. 16 Q. Let me ask you this, Dr. Cosgrove handled the 17 colon, handled the liver, handled the bloody area in 18 the abdomen and then closed the chest. 19 MS. SANDACZ: Objection. 20 Go ahead. Sorry. 21 BY MR. GUTTMAN: 22 Q. Could that have been the mechanism for 23 transmitting the Klebsiella to the pleural space? 24 MS. SANDACZ: Objection. 25 Go ahead. 41 1 A. I don't think so for the same reason, again, it 2 was five days later before he manifested signs of 3 infection there. And I think earlier on in the 4 questions we were discussing whether this Klebsiella 5 was a nosocomial infection. 6 You know, if it was a nosocomial infection, then 7 it didn't come from his gut, it came from the 8 environment, the hospital, people's hands, the phone 9 mites. You can't be a sick patient in a hospital 10 without being colonized with a different set of 11 bacteria. 12 Q. By the need to do the second surgery again you 13 exposed him to many more of these factors, more 14 intubation, more surgical instruments, more hospital 15 staff, more time in the OR, all of those things are 16 risk factors for infection, aren't they? 17 MS. SANDACZ: Objection to 18 hospital staff. 19 You mean as opposed to staph? 20 A. I don't think the instruments would have an 21 effect. If it led to a significantly prolonged 22 intubation, that would lead to more colonization. 23 Q. And more time on a ventilator. 24 A. We are talking a matter of days versus hours. I 25 think hours isn't significant, but if it was many more 42 1 days it would be significant. 2 Q. Isn't there a considerably higher risk of 3 postoperative infection associated with reoperation 4 than with initial operations? 5 A. Again, I think in the CT surgery world when you 6 go into the chest again, those patients are at higher 7 risk for infection. I'm not sure that going in to 8 repair a liver laceration -- 9 Q. They did reopen the chest again, too, didn't 10 they? 11 A. They didn't redo the valve and do a full 12 sternotomy. 13 Q. They reopened the minithoracotomy incision, 14 didn't they? 15 A. Again, I'm not sure how the minithoracotomy fits 16 into the picture. I think a lot of times these things 17 are true and unrelated in that the patients that need a 18 redo are higher risk patients to begin with, and those 19 higher risk patients to begin with, you know, are 20 higher risks for infection. 21 In other words, there's an association between 22 needing to go back in emergently and high risk of 23 infection down the line when it is the full cardiac 24 surgery when the patients were sicker to begin with; do 25 you know what I'm saying? 43 1 Q. In this case that wasn't, true, though. 2 A. Correct, but we are talking about a general 3 association. 4 Q. A lot of what you do in infectious disease is 5 based upon general association, isn't it? 6 A. That's such an open ended question, you know, in 7 infectious diseases we try to isolate the site of 8 infection and recommend tests for isolating the site of 9 infection and give specific therapy. We are trying to 10 be more concrete. 11 Q. You are also looking for risk factors associated 12 with certain infections and trends, and certain events 13 tend to be associated with certain infections? 14 A. In some cases, yes. 15 Q. During the five-day period that -- I guess it is 16 five days until you say he became infected, would you 17 describe Halevi as immunocompromised in any way? 18 A. Not the way we use that term, no. 19 Q. Was his immune system at all compromised? 20 A. Not in the way we use that term, no. 21 Q. Was it stressed? 22 A. I think anybody who undergoes cardiac surgery is 23 probably stressed. I think by the 10th those stresses 24 were resolving. 25 Q. Wasn't the large laparotomy incision an 44 1 additional stressor? 2 A. I'm sure it wasn't -- in some ways probably was 3 an additional stressor, he had to heal it and 4 everything, but I don't think it was significant. 5 Q. Now, the liver laceration and repair needed to 6 be healed as well, correct? 7 A. Correct. 8 Q. Would that be an additional stressor? 9 A. Just in the big picture? 10 Q. M-hm. 11 A. I guess. 12 Q. I don't think we went into this, if we did I'm 13 sure you'll object, would you describe Klebsiella 14 pneumoniae as an opportunistic infection? 15 A. No. 16 Q. It is not. 17 A. No. 18 Q. How would you define the term opportunistic 19 infection? 20 A. Opportunistic infections are bacteria -- let me 21 rephrase that, they are microbes or pathogens that 22 don't normally cause infection in people with normal 23 immune systems but can cause infections in people who 24 have abnormal immune systems. And Klebsiella 25 pneumoniae can cause, I've seen it many times, can 45 1 cause infections in people with normal immune systems. 2 Q. In normal immune systems when it's confined to 3 their colon? 4 A. Well, I've seen Klebsiella cause line 5 infections, pneumonia, urinary tract infections, sepsis 6 syndromes in people who weren't immunosuppressed, and 7 opportunists, we think of organisms that don't normally 8 cause infections in people. 9 Q. Now, are you aware that there's a higher rate of 10 nosocomial bloodstream infections associated with 11 surgical intensive care units than with cardiac 12 intensive care units? 13 A. No. 14 Q. You weren't aware of that particularly at the 15 Cleveland Clinic during the period of time that we are 16 talking about? 17 A. Not really, no. 18 Q. As part of your practice do you look at 19 patients' x-rays and x-ray reports and so on, chest 20 x-rays? 21 A. When I'm consulting on a patient or a patient 22 under my care I like whenever possible to look at the 23 x-rays and I like to review the x-rays with the 24 radiologist. 25 Q. Have you reviewed either the -- 46 1 MR. GUTTMAN: By the way, 2 you owe me x-rays, please? 3 MS. SANDACZ: As soon as we 4 went home from the last one I E-mailed 5 her, but I will call her. 6 MR. GUTTMAN: Those have 7 become rather important. 8 BY MR. GUTTMAN: 9 Q. Have you reviewed either the x-rays or the x-ray 10 -- have you reviewed the x-rays taken on Mr. Halevi on 11 I think it's the 15th? 12 A. No. 13 Q. Have you reviewed the reports? 14 A. Yes. 15 Q. Have you seen the reference to the lung 16 resection? 17 A. Yes. 18 Q. If in fact there were a lung injury that were 19 sewn, sutured, I should say, would that have any impact 20 upon any of your opinions in this case? 21 A. No. 22 Q. What about if Dr. Cosgrove had dropped some 23 clips into the chest cavity and they were allowed to 24 remain? 25 MS. SANDACZ: Objection. 47 1 Go ahead. 2 BY MR. GUTTMAN: 3 Q. Would those have promoted the infection we are 4 talking about? 5 A. Foreign objects can be associated with 6 infection. I don't think you need to invoke that in 7 this case. 8 Q. Need to invoke it or -- 9 A. By need to invoke I mean there was -- the 10 scenario rings true without that happening, if you know 11 what I mean. 12 Q. But it is also possible that those clips played 13 a role in this infection. 14 MS. SANDACZ: Objection. 15 A. I'm not aware that he dropped any clips in. I 16 know there was this x-ray report that I think was 17 possibly misinterpreted. 18 Q. In your experience do radiologists often 19 misinterpret the presence of clips? 20 A. Well, radiologists are existing in a vacuum, in 21 a dark room with no lights looking at an x-ray. They 22 don't know often what all has happened to the patient, 23 they describe what's there, but interpreting where it 24 came from and what it is associated with, they are 25 often wrong. 48 1 Q. Are you aware the next day two different 2 radiologists interpreted the x-ray pictures the same 3 way? 4 A. It doesn't change my opinion. 5 Q. The x-rays taken on the 11th, 12th, which show 6 the increase in pleural effusion, we are talking about 7 September, show blunting of both costophrenic angles. 8 Is that significant in any way to you as a 9 diagnostician? 10 A. He has bilateral pleural effusion. 11 Q. What about the hypoinflation of the lungs? 12 A. That can be a lot of things, not taking a deep 13 breath when they are taking the x-ray. 14 Q. Can it mean an injury to the lung? 15 A. I don't know that, no. 16 Q. No, it couldn't, or no, you don't know that? 17 A. I don't know that there is an association with a 18 clinical injury to the lung and not taking a deep 19 breath. In my medical knowledge I don't think it would 20 preclude somebody from taking a deep breath. The term 21 injury is pretty general. 22 Q. If there was some kind of a laceration or a 23 puncture wound to the right lung, might that be a cause 24 of the hypoinflation? 25 A. What I would expect to see would be air leaking, 49 1 you know, pneumothorax in that situation. I don't know 2 whether that would be associated with not being able to 3 inflate your lung or not. 4 Q. Take care of your patients. 5 (Thereupon, there was a brief 6 recess.) 7 BY MR. GUTTMAN: 8 Q. Doctor, let's look at the differential blood 9 counts of September 14th for a minute. For our 10 purposes, page 461 of the record. 11 A. Here is the differential, okay. 12 On the 14th? 13 Q. Yes. 14 A. Okay. 15 Q. You see where it seems to suggest shift left, 16 shift left, shift left? 17 A. Mild, yes. 18 Q. Is that the beginning of the septic process 19 then? 20 A. I'm not one who puts a lot of stake in left 21 shift, especially when it's just the neutrophils, when 22 I don't see bands and things. That could have been. 23 But the next day his white count really jumped 24 and I think that's much more dramatic. I guess on the 25 16th his white count went to almost 24,000, total white 50 1 count. On the 15th his white count actually went down. 2 His white count was 17 on the 14th, 14 on the 15th, and 3 then his sepsis syndrome began the evening of the 15th. 4 And the next morning his white count was 23,000 5 and the next day his white count was 45,000 which 6 indicates that he is again capable of mounting a really 7 robust response to this infection. 8 Q. By the way, on this one- to two-day incubation 9 period, can you cite me to any article, text, treatise 10 that says that? 11 A. No. 12 Q. Just to make sure I'm clear on the record, 13 you're not going to be expressing any opinions on the 14 standard of care at trial, are you? 15 A. No. 16 MS. SANDACZ: As to the 17 issue of the liver laceration? 18 MR. GUTTMAN: The liver 19 laceration, correct. 20 MS. SANDACZ: If you ask him 21 whether or not Dr. Longworth met the 22 standard of care, if that becomes an 23 issue. 24 MR. GUTTMAN: I don't 25 believe that we were. We are not accusing 51 1 Dr. Longworth of anything that I know. 2 BY MR. GUTTMAN: 3 Q. Let me ask you this, on the 24th of September 4 there's a notation that TPN was going to be begun, 5 effectively meaning Halevi was kept off nutrition for 6 about 10 days. 7 Was that appropriate in your judgment? 8 A. I would have to go back and look at the records. 9 Do they try to give tube feeds in that time? 10 Q. No. 11 A. It's a tricky issue because TPN is associated 12 with complications and so when you have someone who is 13 young and who is so healthy, as you think he is going 14 to turn the corner and get better and you are going to 15 use his intestinal system, you think let's not do TPN, 16 and then you reach a point, let's start TPN because we 17 can see that it's going to be a few more days and we 18 could have started three days ago but we thought he was 19 getting better. That's a common scenario. 20 Q. It's my understanding that surgical incisions 21 heal from the inside out. Would the denial of 22 nutrition during that 10-day period in your opinion 23 have any impact upon the healing of Mr. Halevi's 24 abdominal incisions, laparotomy incisions? 25 A. No. 52 1 Q. Do you have any opinion as to whether that lack 2 of nutrition for those 10 days was in any way related 3 to the incisional hernia which he experienced later? 4 A. No. 5 Q. Are you aware by the way that his laparotomy 6 incision herniated? 7 A. I have heard this. 8 Q. Were you shown any of the photographs? 9 A. No. 10 Q. Doctor, you indicated that the Klebsiella was in 11 a hematoma in the right pleural space? 12 A. Correct. 13 Q. Which hematoma was that, the one taken out on 14 the 16th, 20th, 30th, which one? 15 A. He had fluid and blood in his right pleural 16 space probably from the 9th until after the last 17 surgery he had, so they are all -- it is all sort of a 18 continuum. 19 Q. They were evacuating hematoma, for example, on 20 the 16th, they did a right thoracotomy and evacuated an 21 800 milliliter serosanguineous fluid hematoma. 22 A. Right. 23 Q. The note remarks did not appear infected. 24 Is that something you can tell visually in your 25 experience? 53 1 A. You can sometimes. If it's serosanguineous and 2 it is cloudy it may indicate that it's infected. I 3 believe the fluid from the 16th grew Klebsiella. 4 Q. Now, on the 30th there's a notation about one to 5 two liters of old clotted blood being removed. 6 Do you have any opinion as to what old means? 7 A. No. 8 Q. Could it have been there as long as the 9th? 9 A. I don't know. 10 THE WITNESS: Can I make a 11 quick phone call? 12 MR. GUTTMAN: Sure. 13 (Thereupon, there was a brief 14 recess.) 15 BY MR. GUTTMAN: 16 Q. I believe that Klebsiella pneumoniae was also 17 cultured from the central venous line on September 18 15th. 19 A. From the contact tip? 20 Q. Yes. 21 A. Or from a blood culture tube? 22 Q. Well, let's make sure. 23 MS. SANDACZ: What date? 24 MR. GUTTMAN: September 25 15th. 54 1 BY MR. GUTTMAN: 2 Q. Blood culture. 3 A. I didn't recall that. I certainly wouldn't bet 4 the farm. 5 Q. The fact that the blood cultures taken on the 6 11th and 13th that were negative, it says no growth, 7 six days, I'm looking at the test, that means that they 8 were waiting for six days to evaluate whether the 9 culture would be positive, correct? 10 A. They hold them for six days because some rare 11 organisms may not show up for the first two or three 12 days. 13 Q. Well, did any of the cultures taken earlier than 14 the 15th culture Klebsiella pneumoniae? 15 A. No. 16 Q. Now, is there an incubation period for infection 17 in the bloodstream? 18 A. There's a period of time required for the 19 bacteria to replicate in the blood culture media before 20 the machine says it's positive and that can vary 21 anywhere from hours to days. 22 Q. How many days? 23 A. On average within 24 hours. There are very rare 24 organisms, certainly not Klebsiella, but rare organisms 25 that may take several days. Something like Klebsiella 55 1 within 8 or 10 hours, the machine they use, I'm not 2 sure exactly what they use in the microbiology lab at 3 this point, they have a machine that looks for 4 turbidity in the blood culture medium, and that's going 5 to show positive and they are going to start doing the 6 tests to identify Klebsiella. 7 Q. The question I'm asking you is this, when we are 8 talking about the hematoma sites, it is fair to talk 9 about inoculation of the site? 10 Would the same language be appropriate for the 11 bloodstream? 12 A. Not really. 13 Q. What language would you use in terms of how the 14 bloodstream would have the infection? 15 A. Well, usually the blood is either infected or it 16 isn't. 17 Q. Okay. Does it take time from the time the 18 Klebsiella -- the Klebsiella to grow to a sufficient 19 bacterial strength? 20 A. The way you do blood cultures, you have to have 21 a certain number of organisms in the blood in order to 22 have a positive blood culture to yield changes, but in 23 general, you know, if you get one bacteria in the 24 bottle it will grow. The issue is if the density of 25 the bacteria is low, if you take out 5 ccs of blood, 56 1 there's no bacteria in the blood, that's how it works. 2 Q. Doctor, is it your testimony then that Roni 3 Halevi went from aseptic to septic to multiorgan 4 failure all in the space of 24 hours? 5 A. Correct. 6 Q. And the sepsis was that powerful that quickly? 7 A. Correct. 8 Q. Isn't that highly unusual in a young healthy 9 man? 10 A. Not at all. There's some organisms that can 11 kill a young person in 18 hours. 12 Q. Is Klebsiella pneumoniae such a strong 13 bacteria? A. It's very strong. 14 Q. Now, isn't it more likely that the stages that 15 led up to this are really what happened in the first 16 surgery -- the injury period? 17 A. I don't understand the question. 18 Q. Okay. My understanding is that usually before 19 you get multiorgan failure you're going to get an 20 episode of physiologic shock. We had that because of 21 the bleeding and so on. You need a resuscitation, 22 maybe, maybe not; you had stable hypermetabolism and 23 you had kidney and liver failure coming over a period 24 of days. Isn't there a proximal connection between the 25 two? 57 1 MS. SANDACZ: Objection. 2 A. Absolutely not. As a matter of fact, multiorgan 3 failure you get from sepsis is more than just 4 hypotension, it is the bacteria toxins and in the 5 immune system. 6 Q. Didn't the liver bleed put a stress on the 7 kidneys and also weaken the immune system that way? 8 A. Not at all. And I believe his kidney function 9 was good up until the 15th, 16th, 17th. 10 Q. By the way, what percentage of Klebsiella 11 pneumoniae is Timentin resistant? 12 A. You have to ask the question in a different way, 13 so you can ask the question what percentage of 14 Klebsiella pneumoniae isolated from an intensive care 15 unit or from the community or just anywhere, so those 16 that are -- 17 Q. Hospital acquired. 18 A. -- hospital acquired, quite a few. 19 In the last two or three years it has been 20 recognized. When this happened we were just on the 21 recognition of an epidemic of a type of Klebsiella -- 22 not an epidemic, but recognition that there's a type of 23 Klebsiella that produced an enzyme that inactivated 24 some of the more common antibiotics used. 25 Q. So therefore today you would have followed a 58 1 different -- in a patient similar to Ron Halevi you 2 would have followed a different antibiotic regimen? 3 A. You tend to base your antibiotics on local 4 conditions, so I'm sure that the doctors at the 5 Cleveland Clinic know what's happening in their ICUs, 6 so depending on what's happened in the last year or 7 two, they might have chosen different antibiotics. 8 Q. And you would have, I gather? 9 A. I don't really have firsthand knowledge for what 10 their microbiology is. We use a very similar 11 antibiotic in this hospital in a first choice in a 12 patient like this, Piperacillin Tazobactam. 13 Q. I am going to ask you to spell that for her 14 because she will hate us in the morning if you don't. 15 A. Zosyn is also a combination that is analogous to 16 Piperacillin Tazobactam. 17 Q. This was a Klebsiella pneumoniae that was 18 Timentin resistant? 19 A. As it turned out, correct. 20 Q. In fact, many Klebsiella pneumoniae strains are 21 Timentin resistant, correct? 22 A. Year 2000 it might be. I don't think that was 23 the case in '96. They also gave him a dose of 24 Gentamicin which kind of hedges your bets. 25 Q. It is a broad spectrum antibiotic as well, isn't 59 1 it? 2 A. That's particularly for gram negatives and it 3 kind of hedges your bets against the Timentin not 4 working. Gives you two gram-negative antibiotics. 5 Q. Although they did decide they needed to change 6 the antibiotic, didn't they? 7 A. Correct. 8 Q. What did they change it to? 9 A. I know they used Cipro at some point. I have to 10 look at Dr. Longworth's notes. Let me look at 11 Dr. Longworth's notes. 12 MS. SANDACZ: The orders? 13 THE WITNESS: Infectious 14 disease copious notes. 15 A. Ceftazidime and Tobramycin? 16 Q. Shouldn't those have been administered first? 17 MS. SANDACZ: Objection. 18 A. Absolutely not. There's just as much -- there's 19 equal chance I think it would have been resistant to 20 those. The beta-lactam inhibitor combinations are an 21 appropriate first choice in this patient. 22 MR. GUTTMAN: Nothing 23 further. 24 MS. SANDACZ: You want to 25 read it? 60 1 Up to you. It was pretty 2 straightforward. 3 THE WITNESS: It's okay, do 4 you waive? 5 MS. SANDACZ: You can do 6 that, up to you. 7 THE WITNESS: Usually if 8 there's something that I spoke too fast, 9 hopefully common sense would prevail. 10 MS. SANDACZ: Up to you. 11 THE WITNESS: That's okay, I 12 don't need to read. 13 - - - 14 (DEPOSITION CONCLUDED.) 15 (SIGNATURE WAIVED.) 16 - - - 17 18 19 20 21 22 23 24 25 61 1 State of Ohio, ) SS: CERTIFICATE 2 County of Cuyahoga. ) 3 I, Janet M. Hoffmaster, a Registered Professional 4 Reporter and Notary Public within and for the State of 5 Ohio, duly commissioned and qualified, do hereby 6 certify that the within-named witness, KEITH B. 7 ARMITAGE, M.D., was by me first duly sworn to tell the 8 truth, the whole truth and nothing but the truth in the 9 cause aforesaid; that the testimony then given by him 10 was reduced to stenotypy, and afterwards transcribed by 11 me through the process of computer-aided transcription, 12 and that the foregoing is a true and correct transcript 13 of the testimony so given by him as aforesaid. 14 I do further certify that this sworn statement was 15 taken at the time and place in the foregoing caption 16 specified. 17 I do further certify that I am not a relative, 18 employee or attorney of either party, or otherwise 19 interested in the event of this action. 20 IN WITNESS WHEREOF, I have hereunto set my hand 21 and affixed my seal of office at Cleveland, Ohio, on 22 this 15th day of March 2000. 23 _____________________________________________ 24 Janet M. Hoffmaster, RPR and Notary Public in and for the State of Ohio. 25 My Commission expires September 12, 2002.