0160 1 IN THE COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO 2 AMNE ORRA, INDIVIDUALLY 3 Plaintiff, 4 CASE NO. CV-07-645828 VS. JUDGE BRIDGET MCCAFFERTY 5 CLEVELAND CLINIC FOUNDATION, ET AL. 6 Defendants. 7 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 8 VIDEOTAPED DEPOSITION OF 9 ROOSEVELT BRYANT, III, M.D. 10 VOLUME II 11 July 25, 2008 8:31 a.m. 12 Houston Marriott Medical Center Hotel 13 6580 Fannin Street Houston, Texas 77030 14 Judy H. Gallo, CSR, in and for the State of Texas 15 16 17 18 19 20 21 22 23 24 25 0161 1 APPEARANCES 2 . 3 FOR THE PLAINTIFF(S): 4 BECKER & MISHKIND CO., L.P.A. 5 JESSICA A. PERSE (0078823) 6 (VIA TELEPHONE) 7 Skylight Office Tower 8 1660 West 2nd Street, Suite 660 9 Cleveland, Ohio 44113 10 . 11 FOR THE DEFENDANT(S): 12 ROETZEL & ANDRESS 13 INGRID KINKOPF-ZAJAC, ESQUIRE 14 1375 East Ninth Street 15 One Cleveland Center, 9th Floor 16 Cleveland, Ohio 44114 17 . 18 ALSO PRESENT: 19 JAY MCCLAIN, VIDEOGRAPHER 20 . 21 . 22 . 23 . 24 . 25 . 0162 1 Videotaped Deposition of 2 Roosevelt Bryant, III, M.D. 3 Volume II 4 July 25, 2008 5 THE VIDEOGRAPHER: We are on the 6 record. The time is 8:31 a.m. Today is 7 July the 25th, 2008. This is the 8 continuation of the deposition of Roosevelt 9 Bryant, M.D. May the court reporter re -- 10 re-swear in the witness. 11 ROOSEVELT BRYANT, III, M.D., having 12 been re-sworn, testified as follows: 13 CONTINUED DIRECT EXAMINATION 14 Q. (By Ms. Perse) Okay. Dr. Bryant? 15 A. Yes, ma'am. 16 Q. Okay. This is -- I'd -- I'd like 17 to thank you for, you know, making the time 18 to -- to come back here for part two of your 19 deposition. I wanted to reintroduce myself. 20 I'm Jessica Perse. I'm the attorney for the 21 Orra family in the matter that's pending 22 before a court in Cuyahoga County. And I 23 just want to let you know that the same 24 ground rules apply. If you don't understand a 25 question, feel free to ask me to reword it. 0163 1 If -- we -- we have the added disadvantage 2 of working long-distance on this. So we have 3 the technical constraints of trying to 4 communicate by phone. So if you can't hear 5 me, I would ask you to make sure to let me 6 know, and we'll try to fix whatever snafus 7 there are on the way. And, likewise, I want 8 to make sure that I can hear you. Are you 9 agreeable to that? 10 A. Yes. 11 Q. Okay. Doctor, we -- we left off, 12 the last time was discussing your involvement 13 in Dr. Orra's cardiac procedure on Dec -- on 14 November 30th, 2005. I just want -- by way 15 of review, I just want to confirm you were 16 the first assistant at the time of Dr. Orra's 17 surgery on November 30th, 2005? 18 A. That is correct. 19 Q. Okay. And how about if we begin 20 with you telling me, taking me through your 21 recollection of that operation. When you met 22 Dr. Orra, and what your participation in the 23 operating room was? 24 MS. KINKOPF-ZAJAC: You want him 25 to tell what you he remembers from his 0164 1 recollection? 2 MS. PERSE: What he remembers, 3 yes. 4 MS. KINKOPF-ZAJAC: Okay. 5 A. Regarding the entire operation or 6 -- or my involvement in the operation? 7 Q. (By Ms. Perse) Well, what you 8 remember from the op -- day of the operation. 9 Your involvement? 10 A. Okay. The patient was being 11 operated on for an atrial septal defect. 12 MS. KINKOPF-ZAJAC: She's asking 13 what you remember. Okay. 14 A. Correct. And for my involvement, 15 I opened the patient's chest. 16 Q. (By Ms. Perse) Okay. And I'm 17 going to excuse you. I'm going to ask you to 18 stop for a second, Doctor. 19 Your voice is very distant and 20 you're breaking in and out. Can -- can you 21 move any closer to the phone? 22 A. Is that -- 23 THE VIDEOGRAPHER: We have -- we 24 have a -- this is the videographer, ma'am. 25 We have a short phone cord in here, and 0165 1 we're trying to make do with a short phone 2 cord right now. And we're just doing -- 3 trying to do the best we can over here. 4 MS PERSE: Okay. Then I'm going 5 to have ask the doctor to speak up because 6 I'm -- I'm just not understanding a lot 7 of -- 8 THE WITNESS: Sure. 9 MS. PERSE: -- what he says and 10 don't him to -- 11 MS. KINKOPF-ZAJAC: Okay. 12 MS. PERSE: -- be wasting his 13 time. 14 A. So my -- my recollection of the 15 case was -- my role as Dr. Sabik's assistant 16 for the case. I placed the patient -- I 17 cannulated the patient for cardiopulmonary 18 bypass. And then Dr. Sabik came into the 19 operating room and repaired his atrial septal 20 defect. 21 Q. And tell me a little bit -- I 22 missed the word that you said, something 23 about cardiopulmonary bypass. What was that 24 word? 25 A. I cannulated the patient for 0166 1 cardiopulmonary bypass and Dr. Sabik came in, 2 initiated bypass, and repaired the patient's 3 atrial septal defect. 4 Q. Did you -- with regards to the 5 repair of the atrial septal defect. What was 6 your participation? 7 A. I assisted Dr. Sabik while he 8 repaired the defect. 9 Q. And can you tell me what you did 10 as the assistant? 11 A. As the assistant, I helped follow 12 his stitches as the defect was closed. 13 Q. And how did he close the defect? 14 A. He used pericardium. 15 Q. And did you -- were you involved 16 at all in the retrieval of the pericardium? 17 A. I assisted Dr. Sabik while he 18 retrieved the pericardium. 19 Q. And how was that done? 20 A. I -- I -- I can't tell you 21 specifically how we did it, but pericardium 22 was used. 23 Q. In general, when a pericardium is 24 used to patch a hole in the heart, when is 25 that retrieval performed? 0167 1 MS. KINKOPF-ZAJAC: Objection. 2 Q. (By Ms. Perse) Before cannulation 3 or after? 4 MS. KINKOPF-ZAJAC: Objection. Go 5 ahead. 6 A. Again -- again, I can't tell you 7 specifically for this case, but pericardium 8 was used to close the defect. 9 Q. (By Ms. Perse) I understand that. 10 And I am saying in your practice, in the 11 closure of an ASD, when is the pericardium 12 harvested, if you will? 13 A. In gen -- 14 MS. KINKOPF-ZAJAC: Objection. Go 15 ahead. 16 A. In gen -- for this -- for this 17 case, I can't tell you specifically when the 18 pericardium was harvested. 19 Q. (By Ms. Perse) And I'm not asking 20 you for this case. I'm asking you, when you 21 approach an open ASD repair and you use a 22 pericardial patch, when is the pericardium 23 harvested -- 24 MS. KINKOPF-ZAJAC: Object. 25 Q. (By Ms. Perse) -- for use in the 0168 1 ASD repair? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. For this case, I can't tell you 4 specifically when the pericardium was 5 harvested. 6 Q. (By Ms. Perse) And I'm not asking 7 you that. I -- I need to be really clear. 8 Let me ask you -- start with, have you 9 harvested pericardium on other cases for ASD 10 repairs? 11 A. Not personally. 12 Q. So you've never had the opportunity 13 to harvest the pericardium? 14 A. I've assisted in retrieving 15 pericardium for ASD closures. 16 Q. Okay. And when is the pericardium 17 retrieved for ASD closure? At what point in 18 the procedure? 19 MS. KINKOPF-ZAJAC: Objection to 20 the general nature of the question. If you 21 can answer it, Doctor. 22 MS. PERSE: I'm sorry. I didn't 23 hear you, Ingrid. 24 MS. KINKOPF-ZAJAC: I objected to 25 the general nature of the question and said 0169 1 if he could answer it, he could go ahead and 2 answer it. Go ahead. 3 A. In -- in this particular -- in -- 4 in the situation that I'm in right now, the 5 practice that I'm in at this moment, the 6 pericardium is harvested when -- when the 7 pericardium is opened. 8 Q. And back at the clinic when you -- 9 did you do ASD repairs with pericardium, 10 other than Dr. Orra's case? 11 A. Yes. 12 Q. And at the clinic, what was the 13 practice as to the retrieval of the 14 pericardium for use in an ASD repair? 15 A. I -- I can't answer that 16 specifically. 17 Q. Well, tell me what the potential 18 options would be. When would the pericardium 19 be retrieved? 20 MS. KINKOPF-ZAJAC: Objection. Go 21 ahead. 22 A. That would be dependent on the 23 surgeon that was doing the operation. 24 Q. And I understand that it may be 25 variable. Tell me what the variables -- when 0170 1 that pericardium can be harvested? 2 MS. KINKOPF-ZAJAC: Objection. Go 3 ahead. 4 A. It's -- it's dependent on which 5 surgeon is -- is harvesting the pericardium. 6 Q. (By Ms. Perse) You've made that 7 clear, Doctor. I understand that. What I 8 am asking is, what are the different 9 approaches? I just -- would -- could you 10 outline for me the different ways or the 11 different timing of pericardial retriever -- 12 retrieval? Is it of retrieved before 13 cannulation? 14 MS. KINKOPF-ZAJAC: Objection. Go 15 ahead if you can answer it. 16 A. It can be. 17 Q. (By Ms. Perse) And what is -- what 18 determines when it is harvested before 19 cannulation? 20 MS. KINKOPF-ZAJAC: Objection. I 21 think he said that that's the surgeon's 22 decision. 23 A. It's the surgeon's preference. 24 Q. (By Ms. Perse) Is it ever 25 harvested after cannulation? 0171 1 MS. KINKOPF-ZAJAC: Objection. Go 2 ahead. You can answer. 3 A. It's the surgeon's preference. 4 Q. (By Ms. Perse) And I -- it -- can 5 it -- is it ever harvested after cannulation? 6 MS. KINKOPF-ZAJAC: Objection. Go 7 ahead. 8 A. It's the surgeon's preference. 9 Q. (By Ms. Perse) True or false -- 10 false? Can it be har -- can it be harvested 11 after cannulation? 12 A. It is the surgeon's preference. 13 Q. And in your practice, have you 14 experienced the surgeon's preference -- any 15 surgeons being -- preferring harvesting 16 pericardium after cannulation? 17 MS. KINKOPF-ZAJAC: Objection. Go 18 ahead. 19 A. Depending on the situation. Sure. 20 It can be harvested after cannulation. 21 Q. (By Ms. Perse) When a patient is 22 being operated on for a known ASD, that the 23 intention is to repair the defect with 24 pericardium, is it ever harvested after 25 cannulation? 0172 1 MS. KINKOPF-ZAJAC: Objection. 2 A. It's the surgeon's preference. I 3 can't -- I can't answer it any more 4 specifically than that. 5 Q. (By Ms. Perse) Is it ever can -- 6 used or harvested after cannulation? 7 MS. KINKOPF-ZAJAC: Objection. 8 He's already asked -- answered that question. 9 MS. PERSE: Well, he's answering 10 that it's the surgeon's -- surgeon's 11 preference. But I'm not saying when it would 12 be harvested, in what situation it would be 13 harvested after cannulation. I'm asking, is 14 it ever can -- harvested after cannulation? 15 MS. KINKOPF-ZAJAC: And he's saying 16 that it's the surgeon's decision. Not his 17 decision. So -- so -- 18 MS. PERSE: And I'm not asking 19 whether he made any decisions in the case 20 relative to the pericardium. I'm just trying 21 to find out what the practice is in terms of 22 harvesting the pericardium relative to the 23 timing of cannulation. 24 MS. KINKOPF-ZAJAC: Well, he's 25 already told you, he's never done that. 0173 1 MS. PERSE: He's -- he has told 2 me that he has participated in cases that 3 have pericardium for the closure of ASD 4 defects, and I'd like to have this exchange 5 with the doctor. 6 Q. (By Ms. Perse) Doctor? 7 A. I can't speak for every surgeon, 8 but I can tell you that it is the surgeon's 9 preference when the pericardium is harvested. 10 And when it's harvested is dependent upon 11 that particular surgeon. 12 Q. Dr. Or -- Sabik's practice. When 13 would he harvest the pericardium in an open 14 ASD repair -- 15 MS. KINKOPF-ZAJAC: Objection. 16 Q. (By Ms. Perse) -- relative to the 17 timing of cannulation? 18 MS. KINKOPF-ZAJAC: Objection. 19 A. Again, -- 20 MS. KINKOPF-ZAJAC: If you could 21 speak for Dr. Sabik. 22 A. -- I don't remember exactly when 23 that happened. And I scrubbed this ASD with 24 Dr. Sabik. I do not remember exactly when 25 we harvested the pericardium. 0174 1 Q. (By Ms. Perse) Okay. Did you -- 2 since Dr. Orra's case, did you ever have the 3 opportunity to scrub in an open ASD repair 4 performed by Dr. Sabik? 5 MS. KINKOPF-ZAJAC: Objection. 6 That was asked and answered the first 7 deposition. We are not going to revisit. You 8 can tell her one more time, but we are not 9 going to start re-going over this over and 10 over again. Go ahead. 11 A. No. 12 Q. (By Ms. Perse) Okay. Is it -- 13 did you participate in the -- did you harvest 14 the pericardium in Dr. Orra's case? 15 MS. KINKOPF-ZAJAC: Objection. 16 Asked and answered. Go ahead. 17 A. Again, I don't remember 18 specifically when the pericardium was 19 harvested. 20 Q. (By Ms. Perse) Do you recall if 21 you participated in the harvest? 22 A. I do not recall -- well, I was in 23 the case. So I at least helped Dr. Sabik 24 harvest the pericardium. I don't remember 25 when it was taken. 0175 1 Q. And is it fair to say that you 2 don't recall harvesting the pericardium on 3 your own without Dr. Sabin -- Sabik in 4 attendance? 5 MS. KINKOPF-ZAJAC: In Dr. Orra's 6 case? 7 Q. (By Ms. Perse) In Dr. Orra's case? 8 A. I would say it's fair to say I 9 don't remember when the pericardium was 10 harvested. 11 Q. Doctor, can you tell me why it is 12 that Dr. Orra's case was the only open ASD 13 repair that you performed with Dr. Sabik? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. No. 16 Q. (By Ms. Perse) Was it your choice 17 not to perform any other surgeries with Dr. 18 Sabik? 19 MS. KINKOPF-ZAJAC: Objection. I 20 think he said no. Go ahead. 21 A. Repeat the question, please? 22 Q. (By Ms. Perse) Was it your choice 23 not to participate in any open ASD repairs, 24 such as Dr. Orra's surgery with Dr. Sabik? 25 A. I can't say that I've made any -- 0176 1 any effort not to do more ASDs. 2 Q. Was doctor -- was Michael Orra's 3 open ASD repair the first ASD surgery you 4 did? 5 A. I don't remember the timing of it, 6 but I -- I would say no. 7 Q. Do you know if Dr. Sabik asked 8 that you not participate in any further open 9 ASD repairs with him? 10 A. I do not remember that being the 11 case. 12 Q. This -- Michael Orra's surgery -- 13 did you have opportunity to operate with Dr. 14 Sabik as the attending surgeon at the clinic? 15 A. Yes. 16 Q. Sir, your answer was? 17 A. Yes. 18 Q. And how many surgeries? 19 A. I can't tell you specifically. 20 Q. Can you give me a range? 21 MS KINKOPF-ZAJAC: Objection. If 22 you can -- don't guess. If you can tell. 23 A. Not really. 24 Q. (By Ms. Perse) You have no concept 25 of how many procedures you may have done with 0177 1 Dr. Sabik? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. I can't tell you specific numbers. 4 No. 5 Q. (By Ms. Perse) Well, I'm not 6 asking for specific numbers. I'm asking for 7 a range? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. I don't -- I don't have a range. 10 Q. (By Ms. Perse) Were you ever on 11 probation at any time during your residency 12 at CCF or the Cleveland Clinic? 13 MS. KINKOPF-ZAJAC: Objection. 14 A. No, ma'am. 15 Q. (By Ms. Perse) Did you ever -- 16 were you ever dropped from the program or was 17 that ever discussed with you -- 18 MS. KINKOPF-ZAJAC: Objection. 19 Q. (By Ms. Perse) -- while you were a 20 resident at CCF? 21 MS. KINKOPF-ZAJAC: Objection. Go 22 ahead. 23 A. No, ma'am. 24 Q. (By Ms. Perse) Now, you cannulated 25 Michael Orra in preparation for Dr. Sabik's 0178 1 arrival to the operating room, correct? 2 A. Correct. 3 Q. And do you know how long Dr. Sabik 4 -- or Michael Orra may have been cannulated 5 before Dr. Sabik arrived? 6 A. No, ma'am. 7 Q. Once Michael Orra was cannulated, 8 tell me what you did. 9 A. I waited for Dr. Sabik to arrive. 10 Q. Did you call Dr. Sabik? 11 A. That's our usual routine is we 12 call the staff surgeon and let them know that 13 the patient is cannulated if they aren't 14 already in the operating room. 15 Q. And so at the time you waited for 16 Dr. Sabik, what -- what kind -- do you have 17 any sense of how long that would have been? 18 A. No. 19 Q. And then tell me what you recall 20 about Dr. Sabik's arrival? 21 A. What I recall about his arrival? 22 Q. Yes. 23 A. I don't recall anything specific 24 about his arrival. 25 Q. Did you have any problems with the 0179 1 cannulation in Michael Orra? 2 A. Not that I recall. 3 Q. When Dr. Sabik arrived, what would 4 typically happen? 5 MS. KINKOPF-ZAJAC: Objection. 6 It's -- it's kind of general. I don't know 7 if you can answer that. 8 A. In terms of what? 9 Q. (By Ms. Perse) I'm just trying to 10 get a sense -- kind of putting me in the 11 operation room with you waiting for Dr. 12 Sabik. I'm curious what you -- let's start 13 with what you recall of Dr. Sabik's arrival. 14 MS. KINKOPF-ZAJAC: Asked and 15 answered. Objection. 16 A. I don't recall anything 17 specifically about Dr. Sabik's arrival. 18 Q. (By Ms. Perse) And so if you can't 19 recall Dr. Sabik's arrival, I'm just trying 20 to get a sense of what would happen when Dr. 21 Sabik would come to the room after you 22 cannulated a patient? 23 A. Well, I can -- I can tell you 24 what's in the op note. I don't have any 25 other recollection besides what it says in 0180 1 the operative note. 2 Q. But, in general, in terms of the 3 practice -- Dr. Sabik's practice when you 4 worked with him in other cases, while you 5 were resident at CCF, what would Dr. Sabik 6 typically do once you called him and he 7 arrived in the operating room? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. I -- I -- I can't answer 10 specifically for every case I did with Dr. 11 Sabik. I could tell you -- I can tell you 12 from the operative note what happened in this 13 case. 14 Q. As a resident, working with Dr. 15 Sabik, what were your expectations of what 16 Dr. Sabik would do when you called him? 17 A. He would -- 18 MS. KINKOPF-ZAJAC: Objection. Go 19 ahead. 20 A. When I would call him? 21 Q. (By Ms. Perse) Yeah. When you 22 called him and told him that you had 23 cannulated the patient. The patient was at 24 the next point of the operation. 25 A. My expectation would be that he 0181 1 would come into the operating room. 2 Q. Would he scrub in? 3 A. Generally, yes. 4 Q. Pardon? 5 A. Yes. 6 Q. Do you have any reason to believe 7 that he did not scrub in to Michael Orra's 8 surgery? 9 A. No, ma'am. 10 Q. So what would you expect Dr. Sabik 11 to do once he scrubbed in to the surgery? 12 A. Are you referring specifically to 13 this operation? 14 Q. In -- into Michael Orra's surgery? 15 Yes. 16 A. Well, I can tell you specifically 17 what was done from the operative note. 18 Q. I'm asking what -- what your 19 understanding of Dr. Sabik's practice was? 20 MS. KINKOPF-ZAJAC: I think you're 21 kind of jumping around. Are we talking about 22 Dr. Orra's surgery? Are we talking about in 23 general? 24 MS. PERSE: I'm saying what Dr. 25 Sabik's practice was once Dr. Bryant would 0182 1 call him to the room, and he -- and Dr. 2 Sabik scrubbed in. 3 MS. KINKOPF-ZAJAC: For any 4 patient? 5 MS. PERSE: For any patient. 6 MS. KINKOPF-ZAJAC: Okay. 7 Objection. If you can answer that. 8 A. Well, I can't answer for Dr. 9 Sabik's practice. I can tell you 10 specifically what happened in this case. 11 It's -- it's here in the operative note. 12 Q. (By Ms. Perse) And who dictated 13 the operative note? 14 A. Dr. Sabik. 15 Q. I -- Doctor, do you have the 16 operative note available to you? 17 A. Yes. 18 Q. Will you take a look at the 19 operative note? I notice that there was a 20 -- the dictation was performed on -- on 21 November 30th, 2005, and then there's a 22 notation about revised. 23 A. Okay. 24 Q. On Page 2, on the second page of 25 the operative note. 0183 1 A. Yes, ma'am. 2 Q. Were you aware of an unrevised 3 dictation? 4 A. I have absolutely no idea about 5 that. 6 Q. Would -- would you get these 7 operative notes following the case in your 8 mailbox? 9 A. I'm sorry. Can you say that 10 again? 11 Q. When you performed a procedure at 12 the clinic, would you get a copy of the 13 operative note in your mailbox? 14 A. No, ma'am. 15 Q. To the best of your knowledge, was 16 there an unrevised edition of the procedure 17 note from November 30th, 2005? 18 A. I have absolutely no idea. 19 Q. How long would you expect 20 cannulation to take from -- from the point of 21 opening the chest with the sternal saw to the 22 insertion of the cannulas? 23 MS. KINKOPF-ZAJAC: Objection. Go 24 ahead if you can answer that. 25 A. Are you referring specifically to 0184 1 this case? 2 Q. (By Ms. Perse) For Michael Orra. 3 Yeah. 4 MS. KINKOPF-ZAJAC: Objection. Go 5 ahead. 6 A. I don't remember how long it took. 7 Q. (By Ms. Perse|) Then how long 8 would it typically take in a patient, such as 9 Michael Orra? 10 A. Referring to what in terms of Mr. 11 Orra? 12 Q. Pardon? I didn't hear your 13 answer. 14 MS. KINKOPF-ZAJAC: He -- he 15 didn't understand your question. 16 Q. (By Ms. Perse) Well, I understand 17 he doesn't recall the specifics of doctor -- 18 Michael Orra's case. But I'm just trying to 19 get a sense of an -- an operation like 20 Michael Orra, where he has -- is the resident 21 responsible for opening the chest and 22 cannulating the patient. I'm trying to 23 understand how long that he would anticipate 24 that takes, typically, in a patient such as 25 Michael Orra? 0185 1 MS. KINKOPF-ZAJAC: Objection. Go 2 ahead. Do you understand her question? 3 THE WITNESS: Yes. 4 MS. KINKOPF-ZAJAC: Okay. Go 5 ahead. 6 A. I -- I don't have an anticipated 7 time. 8 Q. (By Ms. Perse) I'm sorry. What 9 was your answer? 10 A. I don't have an anticipated time 11 that it would take to -- to cannulate a 12 patient for bypass. 13 Q. There is no uni -- universal time 14 that you would expect, hey, this took me too 15 long or it went pretty fast? 16 A. No, ma'am. The amount of time 17 would be the amount of time it takes to 18 safely cannulate the patient. Whatever that 19 amount of time is. 20 Q. And I assume that you did safely 21 cannulate Michael Orra? 22 A. I would presume so, based on the 23 operative note. 24 Q. Did you -- I -- I would like to 25 have a better understanding of what Dr. Sabik 0186 1 did once he got to the operating room. And 2 my sense is, that you don't recall anything 3 short of what's in the operative note. I'm 4 going to ask you to review the operative 5 note, and then explain to me, in your own 6 words, what you and Dr. Sabik did on that 7 November 30th, 2005 procedure. 8 MS. KINKOPF-ZAJAC: Well, I'm just 9 going to note an objection. He can read the 10 operative note to you. But if you have 11 specific questions. He's not just going to 12 go into a free, you know, narrative here. I 13 mean, he can read you the operative note if 14 that's what you want. But I think -- 15 Q. (By Ms. Perse) Tell me, Doctor, 16 how was the distal ascending aorta cannulated? 17 A. How was it cannulated? 18 Q. Yes. 19 A. Safely. 20 Q. Well, I want to know procedurally. 21 Can you take me through it? 22 A. What specifically would you like to 23 know? 24 Q. Well, tell me how you -- what 25 instruments you asked for and what you're 0187 1 doing when you put in a cannula into 2 somebody's aorta? 3 A. For this particular case? 4 Q. Yes. 5 A. Well, I don't remember what -- ex 6 -- exactly the instruments that we used. I 7 can -- I can -- I don't remember specifically 8 what instruments we used and what sutures we 9 used if that's what you want to know. 10 Q. I don't want to know specifics. 11 But tell me about what you're doing with that 12 suture? 13 A. Well, a purse string is placed in 14 the aorta to secure the cannula. 15 Q. So you're actually putting stitches 16 into the aorta? 17 A. Correct. 18 Q. And what's the purpose of those 19 sutures? 20 A. It secures the cannula in the 21 aorta. 22 Q. And how is the cannula placed in 23 the aorta? 24 A. With regard to what specifically? 25 Q. I don't -- I don't understand why 0188 1 you're asking that question. I'm -- I'm 2 asking -- you told me you put a purse string 3 in the aorta. 4 A. Correct. 5 Q. And then you insert the cannula. 6 So, do you open the aorta? What do you do? 7 A. Sure. The aorta has to be opened 8 to place the cannula in the aorta. 9 Q. And how do you open the aorta? 10 A. For this particular case? 11 Q. No. Just in general when you 12 cannulate a patient? 13 MS. KINKOPF-ZAJAC: Objection. Go 14 ahead. 15 A. Well, I can't remember about this 16 particular case. But, in general, you need a 17 scalpel to open the aorta. 18 Q. (By Ms. Perse) Do you ever use 19 scissors? 20 MS. KINKOPF-ZAJAC: Objection. 21 MS. PERSE: Pardon? 22 A. Have I personally ever used 23 scissors to open the aorta to cannulate? 24 Q. (By Ms. Perse) That's why I am 25 asking because you said in this particular 0189 1 case or, in general, you used a scalpel. Is 2 there anything else that you could use? 3 A. I personally haven't used scissors 4 to cannulate the aorta. 5 Q. And you did cannulate Mr. -- or 6 Michael Orra? 7 A. Correct. 8 MS. KINKOPF-ZAJAC: Hold on. 9 Wait. Can you hold on for just a second? 10 Somebody is at the door. 11 (Short recess.) 12 MS. KINKOPF-ZAJAC: Okay. Go 13 ahead. I'm sorry. Go ahead, Jessica. I'm 14 sorry. 15 Q. (By Ms. Perse) All right. Then 16 once you put the -- the cannula in the 17 aorta, what do you do with that purse string 18 that you put in the aorta? 19 A. The purse string has a snare on 20 it. So you secure the snare and that holds 21 the cannula in place. 22 Q. And the snare, did you say secures 23 the cannula into place? 24 A. Yes. 25 Q. So once you have the aorta 0190 1 cannulated, what's your next step of 2 cannulation? 3 A. Are you referring to this case, in 4 general, or are you referring to -- 5 Q. I'm referring to the -- I'm 6 looking at the operative note, so that you 7 could use that for your -- for your 8 recollection. 9 A. Uh-huh. 10 Q. But I'm asking what you did in 11 Michael Orra's case or in general? 12 MS. KINKOPF-ZAJAC: Objection. 13 That's two different questions. 14 Q. (By Ms. Perse) Well, let me 15 separate it in -- into -- what did you do 16 next in Michael Orra's case? And you can 17 use the operative notes for your assistance. 18 A. The ascending aorta was cannulated. 19 The superior vena cava and inferior vena cava 20 were cannulated directly. 21 Q. Okay. Tell me how that's done. 22 A. Purse strings are placed in the 23 superior vena cava and inferior vena cava and 24 the cannulas are then inserted. 25 Q. Is there anything like a purse 0191 1 string that's placed around the cannulas? 2 A. Yes. They are. 3 Q. And how are those purse strings 4 secured or snugged down? 5 A. You just answered that question. 6 They are snugged down with snares. 7 Q. Okay. Before Michael Orra's case, 8 how many times had you done a cannulation by 9 yourself? 10 A. A rough estimate -- 11 MS. KINKOPF-ZAJAC: I don't want 12 you to guess. 13 Q. (By Ms. Perse) I am sorry. I did 14 not hear you. 15 MS. KINKOPF-ZAJAC: I don't want 16 you -- 17 A. I -- I -- I don't -- I don't 18 have a -- I don't have an exact number. 19 Q. (By Ms. Perse) Can you give me an 20 estimate? 21 MS. KINKOPF-ZAJAC: Objection. 22 Q. (By Ms. Perse) I'm not going to 23 hold you to the number. I'm just trying to 24 get a sense. 25 MS. KINKOPF-ZAJAC: Don't guess. 0192 1 If you know, you can tell her, but don't 2 guess. 3 A. Again, I don't have an exact 4 number. 5 Q. (By Ms. Perse) I really am just 6 looking for an -- an estimate. What you 7 would expect that you would have done by the 8 second year of your training at the Cleveland 9 Clinic? 10 MS. KINKOPF-ZAJAC: Objection. 11 Asked and answered. 12 A. Again, I -- I don't -- I don't 13 have an exact number. 14 Q. (By Ms. Perse) More than five? 15 MS. KINKOPF-ZAJAC: Objection. 16 A. I don't have an exact number. 17 Q. (By Ms. Perse) When you completed 18 your residency and prepared the logs for the 19 thoracic board, don't you have to give them 20 an exact accounting of how many open heart 21 procedures you've performed? 22 A. Correct. 23 Q. And so what was that number? 24 Just, again, you don't have to give me an 25 exact number. I just want the estimate. 0193 1 MS. KINKOPF-ZAJAC: At the end of 2 his residency? 3 MS. PERSE: What he submitted to 4 the thoracic board, so that he is entitled to 5 sit for his thoracic board. 6 MS. KINKOPF-ZAJAC: Objection. Go 7 ahead. If you remember. 8 A. I -- I don't remember the exact 9 number. 10 Q. (By Ms. Perse) I'm not asking you 11 for the exact number. 12 A. Approximately 675 cases or so. 13 Q. So would it be safe to say that 14 by the time that you participated in Michael 15 Orra's surgery, you would have had either 16 one-third to one-half of those procedures 17 under your belt? 18 MS. KINKOPF-ZAJAC: Objection. 19 A. I can't give you an exact number 20 on that. 21 Q. (By Ms. Perse) I'm not asking for 22 an exact number. I'm asking for an estimate. 23 MS. KINKOPF-ZAJAC: Objection. 24 Asked and answered several times already. 25 MS. PERSE: No. It isn't. I'm 0194 1 -- I think I'm asking different questions. 2 Q. (By Ms. Perse) The question I 3 just put before the doctor was: In November 4 of 2005, would it be a safe bet to say that 5 he had completed one-third to one-half of 6 those 675 cases? 7 A. I'm just -- I just simply can't 8 answer that question. 9 Q. When Dr. Sabik arrived -- or is it 10 safe to say that Dr. Sabik would have arrived 11 at the point in the operative note that's 12 described as the aortic and the superior vena 13 cava and inferior vena cava were cannulated? 14 MS. KINKOPF-ZAJAC: Objection. 15 A. Well, the op note doesn't reflect 16 exactly when he came in the room. 17 Q. (By Ms. Perse) In Michael -- was 18 Michael Orra the first cannulation you had 19 done by yourself? 20 A. No, ma'am. 21 Q. When Dr. Sabik arrived, did he 22 have to redo anything that you had already 23 done? 24 A. I don't remember that being the 25 case. 0195 1 Q. Was Dr. Sabik critical of anything 2 that you had done when Dr. Sabik came into 3 your room -- into the operating room? 4 MS. KINKOPF-ZAJAC: Objection. 5 A. I don't remember that being the 6 case. 7 Q. (By Ms. Perse) I'm sorry. What? 8 A. I don't remember that being the 9 case. 10 Q. I think we reviewed this the last 11 time, but the -- the cardioplegia, did you 12 place that cannula in the aorta? 13 A. No, ma'am. I don't believe that I 14 did. 15 Q. While you were a resident at the 16 clinic, did you ever have an opportunity to 17 place the cannula in the aorta -- 18 MS. KINKOPF-ZAJAC: Objection. 19 Q. (By Ms. Perse) -- or cardioplegia? 20 A. Yes. 21 Q. I'm sorry. Your answer was? 22 A. Yes. 23 Q. Under what circumstances would it 24 be your responsibility to place the 25 cardioplegia cannula in the aor -- aorta as 0196 1 the first assistant? 2 A. That would just depend on what the 3 case was, and which surgeon I was -- I was 4 scrubbed with. What year in training. 5 Q. So what year of training do you 6 have to be before you can put the 7 cardioplegia cannula in the aorta as the 8 first assistant? 9 A. I -- 10 MS. KINKOPF-ZAJAC: Objection. Go 11 ahead. 12 A. I don't think there's a rule for 13 that. 14 Q. (By Ms. Perse) Would first years 15 ever do it? 16 MS. KINKOPF-ZAJAC: Objection. 17 A. I don't know. 18 Q. (By Ms. Perse) As a first year, 19 did you ever do it? 20 A. I don't remember that being the 21 case. 22 Q. So just to be clear, is -- is -- 23 are you telling me that you don't -- as a 24 first year, you did not put an aortic cannula 25 in for car -- cardioplegia? 0197 1 MS. KINKOPF-ZAJAC: Objection. 2 Asked and answered. Go ahead. 3 A. I'm not exactly understanding your 4 question because you said aortic cannula for 5 cardioplegia? 6 Q. (By Ms. Perse) Oh, excuse -- well, 7 the -- I'm looking at the operative note, and 8 they call it a cardioplegia cannula. 9 A. Yes. But they don't call it 10 aortic cannula. 11 Q. But to be clear. Is a -- a 12 cardioplegia cannula placed in the ascending 13 aorta? 14 A. Well, what it says is that 15 antegrade cardioplegia cannula/aortic vent -- 16 Q. I understand that. 17 A. -- was placed in the aorta. 18 Q. I'm talking about that thing. Did 19 you ever do that as a first-year resident? 20 MS. KINKOPF-ZAJAC: Objection. 21 Asked and answered. Go ahead. 22 A. I don't remember that being the 23 case. No, ma'am. 24 Q. (By Ms. Perse) All right. Who put 25 the patient onto cardiopulmonary bypass? 0198 1 A. Dr. Sabik. 2 Q. Who put the -- who cross-clamped 3 the ascending aorta? 4 A. Dr. Sabik. 5 Q. Do you remember Dr. Sabik doing 6 that or how do -- how do you know that? 7 A. Because that is usually what 8 happens when you're a resident at the 9 Cleveland Clinic. 10 Q. That's usually what would happen? 11 I'm sorry. I didn't hear the last part of 12 that. 13 A. Because that's what happened in my 14 training when I was in Ohio. 15 Q. But you don't have a specific 16 recollection to Michael Orra's case about 17 that? 18 A. No, ma'am. I don't. 19 Q. How long after the cardioplegia is 20 given does the heart arrest? 21 A. I can't answer that question 22 specific. It's variable from one patient to 23 the next. 24 Q. What are the variables that 25 determine how long it takes? 0199 1 A. It's patient dependent. That's the 2 primary variable. 3 Q. I'm sorry. I didn't hear you. 4 A. It's patient dependent. That's the 5 primary variable. 6 Q. And what about the patient makes 7 it depen -- affect that timing? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. Well, all patients aren't the same, 10 so. That's as much as I can tell you. 11 Q. (By Ms. Perse) Is there a range? 12 MS. KINKOPF-ZAJAC: Objection. 13 A. I don't have a range to -- to 14 quote you for that. 15 Q. (By Ms. Perse) Do you have certain 16 expectations, based on specific patient 17 characteristics as to how long it would take? 18 A. Not particularly. 19 Q. So in a patient, such as Michael 20 Orra, would his specific characteristics, his 21 disease process, the status of his heart, his 22 body habitus. There would be nothing about 23 that patient that you would be able to 24 determine how long it should take for the 25 heart to be arrested once cardioplegia is 0200 1 administered? 2 MS. KINKOPF-ZAJAC: Objection. Go 3 ahead if you can answer it. 4 A. No, ma'am. 5 Q. (By Ms. Perse) Can we agree that 6 it is important to be sure that the heart is 7 arrested with cardioplegia? 8 MS. KINKOPF-ZAJAC: Objection. Go 9 ahead. 10 A. Yes. We can agree on that. 11 Q. (By Ms. Perse) And why is it 12 important that the heart is arrested? 13 MS. KINKOPF-ZAJAC: Objection. We 14 went through this the first deposition. I'll 15 let him answer this question, but we're not 16 going to revisit everything. Go ahead, Dr. 17 Bryant. 18 A. Why is it important? Myocardial 19 protection. 20 Q. (By Ms. Perse) Doctor? 21 A. Yes, ma'am. 22 Q. The question pending before you? 23 A. I said myocardial protection. 24 Q. Okay. I didn't hear you, so. I 25 apologize. 0201 1 In Michael Orra's case, how long 2 was the heart arrested? 3 A. I do not know that answer. 4 Q. Would that be documented in any 5 record? 6 A. Well, from what I have, I don't 7 see any mention of it. 8 Q. Where would you -- what record 9 would you expect that to be in? 10 A. Well, it -- it -- it is usually 11 recorded in the -- an -- the anes -- the 12 anesthesiologist and -- and -- will have that 13 information. That's usually recorded on their 14 flow sheets from the operation. Also, 15 occasionally surgeons will sometimes dictate 16 that in the operative note. But -- yeah. I 17 -- again, I don't have that information in 18 front of me. So I can't answer that. 19 Q. What is your role as the first 20 assistant in the cardioplegia process? 21 A. What is my role? To help the 22 surgeon. 23 Q. Well, what do you do to help the 24 surgeon with cardioplegia? 25 A. Well, for example, after the 0202 1 cardioplegia needle is inserted by the 2 surgeon, if there's a snare to secure it in 3 the aorta, I would engage the snare. 4 Q. Anything else? 5 A. No, ma'am. 6 Q. Did you give any direction to the 7 perfusionist team? As the first assistant, 8 do you give any direction to the cardio pro 9 -- cardiopulmonary perfusionist team about the 10 cardioplegia? 11 A. No, ma'am. 12 Q. Once the heart is arrested and the 13 aorta is cross-clamped, what takes place after 14 that? 15 MS. KINKOPF-ZAJAC: Are you talking 16 about this particular case? 17 Q. (By Ms. Perse) Let's talk about 18 Michael Orra. What took place? 19 A. Well, according to the operative 20 note -- you said after cross-clamping? 21 Q. Yes. 22 A. It says the heart was arrested 23 with antegrade cold blood cardioplegia. A 24 right atriotomy was performed. Auto -- 25 Q. What -- what is a right atriotomy? 0203 1 A. An incision in the right atrium. 2 Q. And then what happened? 3 A. It says, "Autologous pericardium 4 was then fashioned to the size of the 5 secundum atrial septal defect." 6 Q. Do you recall what Michael Orra's 7 defect looked like? 8 A. No, ma'am. 9 Q. Do you have any sense of -- at 10 all of the dimension? 11 A. No, ma'am. 12 Q. Did it seem big to you, at all? 13 A. I don't remember the -- 14 MS. KINKOPF-ZAJAC: Objection. Go 15 ahead. 16 A. I don't remember the dimensions. 17 Q. (By Ms. Perse) Yeah. And that may 18 be a little bit too specific. 19 In terms of your experience, was 20 it larger than normal? Smaller than normal? 21 MS. KINKOPF-ZAJAC: Objection. 22 A. I don't remember the dimensions. 23 Q. (By Ms. Perse) And I understand 24 that. I'm just trying to get a sense of 25 what -- if it struck you as being larger 0204 1 than most? 2 MS. KINKOPF-ZAJAC: Objection. Go 3 ahead if you can answer it. 4 A. I don't remember the dimensions. 5 Q. (By Ms. Perse) Well, once the 6 atrium is opened -- tell me about the how 7 the pericardium is fashioned or is harvested? 8 A. Again, that's somewhat surgeon 9 dependent, and I don't -- you know, he 10 doesn't describe specifically the way in which 11 that was done in the operative notes. So I 12 can't really go into any more detail than 13 what we have here. 14 Q. Is it possible that you harvested 15 the pericardium before you even cannulated? 16 MS. KINKOPF-ZAJAC: Objection. I 17 think it's been asked and answered. Go 18 ahead. 19 A. I would say, no, based on the 20 operative note. 21 Q. (By Ms. Perse) Well, does the 22 operative note describe the harvesting of the 23 pericardium? 24 A. It does not. 25 Q. So what about the op note tells 0205 1 you that you would not have harvested the 2 pericardium? 3 A. Well, I can't -- I can't -- I 4 can't say specifically when the pericardium 5 was harvested. 6 Q. So you don't know if you did or 7 you did not harvest the pericardium? 8 MS. KINKOPF-ZAJAC: Objection. 9 A. That's fair. 10 Q. (By Ms. Perse) When the patch is 11 placed on the atrial septal defect, is 12 patient in the prone position or is the 13 patient rotated in any way? 14 A. I don't remember any particular 15 changes in patient position for this 16 particular case. 17 Q. Is there any mention of it in the 18 operative note? 19 A. Well, I can read what it says. 20 "Autologous pericardium was then fashioned to 21 the size of the secundum atrial septal 22 defect. It was sutured in place with a 23 running 4-0 Prolene suture." We can 24 continue. I don't -- I don't see any -- any 25 particular mention about anything else in 0206 1 regard to patient positioning. 2 Q. Explain to me what it means when 3 the operative note describes inflating the 4 lungs to de-air the left side of the heart? 5 A. What it means? 6 Q. Well, I don't -- 7 A. Is that what you said? 8 Q. -- understand what is -- well, how 9 -- how are the lungs inflated? 10 A. Well, usually there is a command 11 given by the surgeon to the anesthesiologist. 12 Q. And how does the anesthesiologist 13 inflate the lungs? 14 A. You would really have to ask the 15 anesthesiologist. 16 Q. So if you had an anesthesiologist 17 that was at the head of the table and you 18 asked them to inflate the lungs, and they 19 didn't know how, could you give them any 20 instruction? 21 MS. KINKOPF-ZAJAC: Objection. Go 22 ahead. 23 A. That's -- that's not usually my -- 24 my job. 25 Q. (By Ms. Perse) My question was, 0207 1 could you give them any instruction? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. My answer is that that's not 4 usually my job. 5 Q. (By Ms. Perse) So what would -- 6 resources would you use if an anesthesiologist 7 said "I don't know what you're talking about, 8 Doctor?" 9 MS. KINKOPF-ZAJAC: Objection. If 10 you can answer that, go ahead. 11 A. That -- that -- that usually isn't 12 my job. 13 Q. (By Ms. Perse) So you would tell 14 them you don't know how to inflate the lungs? 15 MS. KINKOPF-ZAJAC: Objection. 16 A. That wasn't the question. 17 Q. (By Ms. Perse) Pardon? My 18 question was, so you would tell the 19 anesthesiologist that you don't know how to 20 inflate the lungs? 21 MS. KINKOPF-ZAJAC: Objection. 22 A. No. 23 Q. So what would you tell them to do? 24 A. To inflate the lungs. 25 Q. And how would they inflate the 0208 1 lungs? 2 A. I -- that's not usually something 3 that I do. So I can't tell you exactly what 4 they do to inflate the lungs. 5 Q. So you do not know how they would 6 inflate the lungs? 7 MS. KINKOPF-ZAJAC: Objection. 8 A. I do not know exactly how the 9 anesthesiologist inflate the lungs. 10 Q. (By Ms. Perse) What about inflating 11 the lungs de-airs the heart, the left side of 12 the heart? 13 A. Are you speaking in general terms? 14 Q. Correct. 15 A. It's called valsalva maneuver. So 16 it increases the blood flow to the left 17 atrium. 18 Q. And increasing the blood flow to 19 the left atrium does what? 20 A. Displaces any air in the atrium 21 with blood. 22 Q. Where does it -- where is it 23 displaced to? 24 A. Out of the heart. 25 Q. Is it out of the heart or out of 0209 1 the left side of the heart? 2 A. Out of the left side of the heart. 3 But it sometimes goes out of the heart. It 4 depends on how much volume you have. 5 Q. In general, is there any reason to 6 rotate the patient during that process? 7 MS. KINKOPF-ZAJAC: Objection. Go 8 ahead. 9 A. That is very surgeon dependent. 10 Q. (By Ms. Perse) I'm sorry. What? 11 A. That is very surgeon dependent. 12 Q. And do you know what Dr. Sabik's 13 practice was with de-airing the heart, the 14 left side of the heart by inflating the 15 lungs? 16 A. No, ma'am. I do not know what 17 Dr. Sabik's practice is. 18 Q. Well, how should the heart be 19 de-aired at this point of the procedure? 20 MS. KINKOPF-ZAJAC: Objection. 21 A. Again, that's very surgeon 22 dependent. 23 Q. (By Ms. Perse) When you are doing 24 a procedure where you as the primary surgeon 25 want to de-air the heart by inflating the 0210 1 lungs. What do you tell the people in the 2 room to do? Take me through that. 3 MS. KINKOPF-ZAJAC: Objection. 4 Well, he's here to talk about his factual 5 involvement with this case. He's not here to 6 talk about as -- as an expert. So you want 7 to ask him about his factual involvement with 8 this particular case? 9 MS. PERSE: Well, I am just trying 10 to understand exactly what happens technically 11 in this kind of a procedure. 12 MS. KINKOPF-ZAJAC: Okay. 13 MS. PERSE: So I do want to ask 14 him what he does. 15 MS. KINKOPF-ZAJAC: Well, he can 16 tell you what he did in this procedure. But 17 as far as what other people did in this 18 procedure, I don't think it is fair for -- 19 to ask him to comment on that. 20 MS. PERSE: Well, I think it's 21 fair of me to ask what he does as the 22 cardiothoracic surgeon. 23 MS. KINKOPF-ZAJAC: He's not a 24 cardiothoracic surgeon. He's in training. 25 And he's not identified as an expert. But, 0211 1 Doctor, I will -- if you can answer her 2 question, go ahead. 3 A. Can you repeat the question? 4 Q. (By Ms. Perse) Let me switch a 5 little bit and ask: What was your 6 understanding of how this procedure was done 7 when you were a second-year resident at the 8 Cleveland Clinic? 9 A. This operation, in particular? 10 Q. No. This point of the procedure, 11 de-airing as you are closing the open atrial 12 septal defect. 13 MS. KINKOPF-ZAJAC: Objection. Go 14 ahead. 15 A. Again, it's just dependent on the 16 surgeon. 17 Q. (By Ms. Perse) But I'm going to 18 ask you to walk me through how the different 19 surgeons would do it as your -- you 20 understood it to be as a second-year resident 21 at the clinic? 22 MS. KINKOPF-ZAJAC: Objection. 23 A. Well, I can't tell you how each 24 one of the surgeons at the Cleveland Clinic 25 de-aired -- 0212 1 Q. Well, tell me the different ways. 2 MS. KINKOPF-ZAJAC: He's still 3 answering your question. 4 MS. PERSE: Oh, I'm sorry. 5 A. I can't tell you how each one of 6 the surgeons de-aired the -- the heart from 7 an ASD closure. 8 Q. (By Ms. Perse) What would be the 9 different ways that different surgeons would 10 do it? Just in general terms? 11 MS. KINKOPF-ZAJAC: Objection. Go 12 ahead. 13 A. Well, I can tell you how it was 14 done in this case. It appears that it was -- 15 it was done by having the lungs inflated. 16 Q. (By Ms. Perse) Is there any other 17 way to do it? 18 MS. KINKOPF-ZAJAC: Objection. Go 19 ahead. 20 A. That's one way to do it. 21 Q. (By Ms. Perse) So there are other 22 ways? 23 A. Sure. It's very surgeon dependent. 24 Q. And what are the other ways? 25 A. Well, the other ways weren't done 0213 1 in this case. I can make a general 2 description about how some people might do 3 it, but this -- 4 Q. That would be great. 5 A. The way that it was done here was 6 to have the lungs inflated. 7 Q. Can you tell me the different 8 ways? 9 A. The -- some people inject saline 10 to displace air. 11 Q. Where is the saline injected? 12 A. Pardon? 13 Q. Where is the saline injected? 14 A. In the left atrium. 15 Q. Any other ways? 16 A. That's pretty much -- that's pretty 17 much it that I -- that I'm aware of. I -- 18 I mean, I'm sure that there are probably 19 numerous ways to -- to accomplish de-airing. 20 Q. And was the saline technique used 21 in Michael Orra? 22 A. I don't recall that being the 23 case. Again, it's described in the operative 24 note that the -- the lungs were inflated to 25 de-air the left side of the heart. 0214 1 Q. Okay. And then once the defect is 2 closed, what -- what happened in Michael 3 Orra's case? 4 MS. KINKOPF-ZAJAC: In the 5 operating room? 6 MS. PERSE: Yes. 7 A. So what the operative note says is 8 that the suture was then tied down. And we, 9 again, inflated the lungs to see if there was 10 any leak across the patch. We could not 11 identify one. 12 Q. (By Ms. Perse) Do you remember 13 that? 14 A. Well, from reading the op note, I 15 do. 16 Q. But you don't have an independent 17 recollection of doing that? 18 A. No, ma'am. 19 Q. And once the defect was closed and 20 there was no leak, what was done next? 21 A. A hot shot dose of cardioplegia 22 was given and the aortic cross-clamp was 23 removed. 24 Q. Tell me what a hot shot dose of 25 cardioplegia is? 0215 1 A. It's just a warm dose of 2 cardioplegia. 3 Q. I'm sorry. What? 4 A. It's a warm dose of cardioplegia. 5 Usually it's given cold. 6 Q. Is the cross-clamp removed as soon 7 as that hot shot dose of cardioplegia is 8 given? 9 A. The operative note says a hot dose 10 of cardioplegia was given and the aortic 11 cross-clamp was removed. I think that was 12 the sequence, according to the operative note. 13 Q. I am sorry, Doctor. You broke up 14 there. Can -- you think that was -- 15 A. I think that was the sequence 16 according to the operative note. A hot shot 17 dose of cardioplegia was given and the aortic 18 cross-clamp was removed. 19 Q. Was anything else done at that 20 point in time? 21 A. Well, the operative note continues. 22 So, yes. 23 Q. But between the closing of the 24 defect and inflating the lungs to -- to make 25 sure there was no leak and the cardioplegia 0216 1 was given and then the cross-clamp removed. 2 Was anything else done? 3 MS. KINKOPF-ZAJAC: Objection. 4 A. According to the operative note, 5 the cross-clamp was removed after the 6 cardioplegia was given. I don't see any 7 other indication in the operative note of 8 anything else. 9 Q. |(By Ms. Perse) And, Doctor, I -- 10 I don't want to be rude and jump in before 11 you answer. I -- I'm really having a hard 12 time hearing you. 13 A. Sure. 14 Q. So if you could speak up. 15 A. Again, according to the operative 16 note. It says a hot shot dose of 17 cardioplegia was given and the aortic 18 cross-clamp was removed. So that's -- that's 19 what was done. 20 Q. And you don't have any independent 21 recollection of anything else happening? 22 A. No, ma'am. 23 MS. KINKOPF-ZAJAC: Just to give 24 you the heads up. We're about the time we 25 need to change the tape. 0217 1 MS. PERSE: Okay. How about if 2 we take a break here? 3 MS. KINKOPF-ZAJAC: Okay. 4 THE VIDEOGRAPHER: We are off the 5 record. It is 9:30 a.m. 6 (Recess taken at 9:30 a.m. until 7 9:35 a.m.) 8 THE VIDEOGRAPHER: We are back on 9 the record. It is 9:35 a.m. 10 Q. (By Ms. Perse) Okay, Doctor? 11 A. Yes, ma'am. 12 Q. All right. You okay if we get 13 started again? 14 A. Sure. 15 Q. All right. We were at the point 16 in the operation where the cross-clamp had 17 been removed. Do you know who removed the 18 cross-clamp? 19 A. Dr. Sabik. 20 Q. And how do you know that? 21 A. Just because that's -- that's 22 usually the way we do it. 23 Q. Do you have a specific recollection 24 of this case? 25 A. Not specifically. 0218 1 Q. And then -- then what happens 2 after the cross-clamp was removed? 3 A. Well, according to the operative 4 note, it says the right atriotomy was closed 5 with two layers of -- of 4-0 Prolene, running 6 4-0 Prolene. 7 Q. Do you know who did that part of 8 the procedure? 9 A. Dr. Sabik. 10 Q. And -- and how do you know that? 11 A. Because that's how we would usually 12 do it. 13 Q. Do you have a specific recollection 14 about this case? 15 A. No, ma'am. 16 Q. Following the closure of the 17 atriotomy, what happened next? 18 A. It says the heart's patient had -- 19 when the heart's patient had adequately 20 recovered, he was weaned from cardiopulmonary 21 bypass without difficulty. 22 Q. And how is the patient weaned from 23 cardiopulmonary bybass? 24 A. Well, usually, the perfusionist is 25 managing this and the surgeon is giving 0219 1 commands about what kind of flows they want 2 to run the patient. When to give volume to 3 the heart. That sort of thing. It's a -- 4 it's a communication between the -- the 5 operating surgeon and the perfusionist. 6 Q. Did you wean the patient from 7 cardiopulmonary bypass? 8 A. No, ma'am. 9 Q. I'm sorry. What was your answer? 10 A. My answer was, that commands are 11 given between the operating surgeon, the staff 12 surgeon, and the -- and the perfusionist, and 13 they coordinate to -- to separate the patient 14 from bypass. 15 Q. And who is the operating surgeon? 16 A. This was Dr. Sabik. 17 Q. Okay. Can the operating surgeon 18 and the staff surgeon be two different 19 people? 20 A. They are usually the same person. 21 Q. But can it be that the operating 22 surgeon and the staff surgeon are two 23 different people? 24 MS. KINKOPF-ZAJAC: Objection. 25 A. They are usually the same person. 0220 1 Q. (By Ms. Perse) I'm sorry. What? 2 A. They are usually the same person. 3 Q. So when I hear usually, that means 4 there are exceptions. So is there a 5 situation where the staff surgeon and the 6 operating surgeon are not the same person? 7 MS. KINKOPF-ZAJAC: Objection. Go 8 ahead. 9 A. Well, for -- for this case, for 10 example, I put -- I cannulated the patient. 11 So at that moment in time, I was the 12 operating surgeon. But the staff surgeon for 13 the case is Dr. Sabik. 14 Q. (By Ms. Perse) So even within a 15 procedure, the staff surgeon and the operating 16 surgeon can be two different people, correct? 17 A. It's -- it's a -- it's a matter 18 of semantics, but I -- I put the patient -- 19 I cannulated the patient for bypass. So at 20 that point, I was the surgeon in the room. 21 Q. You were the operating surgeon at 22 that time? 23 A. At that time. 24 Q. But at the time that the patient 25 was being weaned off of cardiopulmonary 0221 1 bybass, who was the operating surgeon? 2 A. Dr. Sabik. 3 Q. And how do you know that? 4 A. Because that is -- that is our 5 usual way of doing things. 6 Q. You don't have an independent 7 recollection of Dr. Sabik being the operating 8 surgeon at that point in time? 9 A. I'm pretty sure Dr. Sabik was -- 10 was the surgeon then. Took the patient off 11 bypass. Put the patient on bypass. Took the 12 aortic cross-clamp off and repaired the ASD. 13 Q. You're pretty sure. How are you 14 pretty sure? 15 A. I'm certain of it. 16 Q. I'm sorry. What? 17 A. I'm -- I'm certain of it. That's 18 -- that's the way that -- that things are 19 done. 20 Q. Does the op note indicate that Dr. 21 Sabik did this? 22 A. Yes, it is. 23 MS. KINKOPF-ZAJAC: Did what? Did 24 what? 25 Q. (By Ms. Perse) that he had did the 0222 1 a-- arter -- atriotomy closure and weaning 2 the patient off the cardiopulmonary bypass? 3 A. It doesn't say his name. But at 4 the top it says surgeon, Joseph Sabik. 5 Assistant Roosevelt Bryant. 6 Q. So we've already established that 7 at different times in the operating room, the 8 operating surgeon can either be the staff 9 surgeon or the first assistant? 10 A. Well, I would -- I would -- I 11 would -- I would say that is not what we 12 established. What I said was, that at the 13 time that I placed the cannulas for bypass, I 14 was the surgeon in the room. That's what 15 we've been discussing, and that's all that I 16 have established. 17 Q. Do you remember Michael Orra being 18 weaned from cardiopulmonary bypass? 19 A. The specifics of it, I do not. I 20 can tell you from the operative note what it 21 says, is that he was weaned from 22 cardiopulmonary bypass without difficulty. 23 Q. Now, it goes on to describe that 24 Dr. Sabik had some right ventricular 25 dysfunction. Do you remember that? 0223 1 A. I don't remember Dr. Sabik having 2 any right ventricular dysfunction. 3 Q. I'm sorry about that. Michael 4 Orra. The operative note on Michael Orra. 5 It describes the patient had some right 6 ventricular dysfunction. Do you recall that? 7 A. Only from what I see written here. 8 Q. Is there any right ventricular 9 dysfunction described -- well, let me strike 10 that. 11 When you opened Dr. Orra, did you 12 notice any right ventricular dysfunction? 13 A. I think from -- from the last -- 14 previous report that we -- I remember talking 15 about this. I don't remember, you know, 16 specifically what -- recalling what the -- 17 what the ventricle looked like. 18 Q. Was Dr. Orra -- Dr. Sabik present, 19 prior to cannulation? 20 A. No, ma'am. 21 Q. So what basis would -- would -- 22 would Dr. Sabik be able to describe that the 23 right ventricular dysfunction was consistent 24 with preoperatively, if you know? 25 MS. KINKOPF-ZAJAC: Objection. 0224 1 A. I'm sorry. You would have to ask 2 Dr. Sabik. 3 Q. (By Ms. Perse) What are the causes 4 of right ventricular dysfunction? 5 A. In general? 6 Q. With Michael Orra? 7 A. I -- I don't know exactly what the 8 cause of his right ventricular dysfunction is. 9 Q. I'm asking what the potential of 10 right ventricular decannulation in Mr. -- 11 Michael Orra would be? 12 MS. KINKOPF-ZAJAC: At what point? 13 At this point in time? 14 MS. PERSE: I'm -- yeah. I'm 15 talking about the point that's described in 16 the operative note. 17 MS. KINKOPF-ZAJAC: Okay. 18 A. Well, it doesn't say specifically 19 what the cause is. It just says that he had 20 some right ventricular decannulation. 21 Q. (By Ms. Perse) But as a surgeon, 22 whether it be operating surgeon or a first 23 assistant, what is your understanding of the 24 causes of the right ventricular dysfunction in 25 Michael Orra? 0225 1 MS. KINKOPF-ZAJAC: Objection. 2 Q. (By Ms. Perse) At the point in 3 time that it's doc -- documented in the 4 operative note? 5 MS. KINKOPF-ZAJAC: Objection. 6 A. Again, for this particular case, I 7 -- I do not know specifically what the cause 8 of his right ventricular function was -- 9 right ventricular dysfunction was. 10 Q. (By Ms. Perse) And I'm not asking 11 for the specific cause. But what was -- 12 what would be your understanding of the 13 different causes? 14 A. Again, -- 15 MS. KINKOPF-ZAJAC: Objection. Go 16 ahead. 17 A. -- I do not know specifically what 18 the cause of his right ventricular 19 decannulation was. 20 Q. (By Ms. Perse) And I want to be 21 clear. I'm not asking what the cause of his 22 right ventricular dysfunction was. I'm asking 23 what the possibilities would be? 24 MS. KINKOPF-ZAJAC: Objection. 25 A. I don't know specifically what the 0226 1 cause of his right ventricular dysfunction is. 2 Q. (By Ms. Perse) So you have no -- 3 no differential diagnosis at that point in 4 time as to what the causes might be? 5 A. I don't remember specifically what 6 the cause of his right ventricular 7 decannulation was at the time. No. I do 8 not. 9 Q. Let's say that as a second-year 10 resident, Dr. Sabik told you that a patient 11 was experiencing right ventricular 12 decannulation, and Dr. Sabik asked what the 13 potential causes of the right ventricular 14 decannulation would be. What would you tell 15 him? 16 MS. KINKOPF-ZAJAC: Objection. 17 Q. (By Ms. Perse) At this point in 18 the procedure? 19 A. Well, what -- what particular 20 diagnosis is Dr. Sabik asking me about? 21 Q. Well, the diagnosis of right 22 ventricular decannulation? 23 A. In isolation or in association with 24 some sort of procedure? I mean, what is the 25 -- or I don't understand the question. 0227 1 What's the patient's pathology? What is 2 the -- 3 Q. I understand that, Doctor. 4 A. What is the scenario? 5 Q. Let me step back for a second and 6 ask, in a patient, such as Michael Orra, that 7 has undergone an open ASD repair. Has 8 already come off of or been weaned off bypass 9 and the defect has been closed and that 10 patient was experiencing right ventricular 11 decannulation. And Dr. Sabik asked the 12 attending surgeon, asked you, as the first 13 assistant, what the potential causes would be. 14 What would your answer be? 15 MS. KINKOPF-ZAJAC: Objection to 16 the hypothetical. If you can answer that. 17 A. He -- he didn't -- he didn't ask 18 me what the potential causes of right 19 ventricular dysfunction -- 20 Q. (By Ms. Perse) And I didn't ask 21 you if he asked you. I am asking, in the 22 hypothetical, what would your response be to 23 Dr. Sabik? 24 MS. KINKOPF-ZAJAC: Objection to 25 the hypothetical. 0228 1 A. I -- my response would be 2 preoperative right ventricular decannulation. 3 Q. (By Ms. Perse) And would there be 4 any other answers? 5 A. That would -- 6 MS. KINKOPF-ZAJAC: Objection. Go 7 ahead. 8 A. That would be my answer for this 9 particular patient. 10 Q. (By Ms. Perse) No. I'm not asking 11 for this particular patient. But what kind 12 of differ -- differential diagnosis would you 13 formulate and offer to your attending surgeon 14 in the operating room? 15 MS. KINKOPF-ZAJAC: Objection to 16 the hypothetical. 17 A. The question, as I understood it, 18 was relating to this particular patient or a 19 patient like Michael Orra. So in this 20 particular case, my answer would be 21 preoperative right ventricular decannulation. 22 Q. (By Ms. Perse) And you would have 23 no other possible diagnoses? 24 MS. KINKOPF-ZAJAC: Objection. 25 A. My answer for this patient would 0229 1 be preoperative right ventricular 2 decannulation. 3 Q. (By Ms. Perse) And I'm not asking 4 specifically for Michael Orra. I'm saying a 5 patient like Michael Orra. You would have no 6 other considerations in your mind at that 7 time as a second-year resident being asked 8 that question by Dr. Sabik? 9 MS. KINKOPF-ZAJAC: Objection. Go 10 ahead. 11 A. My answer for this patient would 12 be preoperative right ventricular 13 decannulation. 14 Q. (By Ms. Perse) And is that the 15 only possible medical explanation? 16 MS. KINKOPF-ZAJAC: Objection. 17 Asked and answered several times. Go ahead, 18 Doctor. Tell her one more time. 19 A. Again, my answer for this patient 20 would be preoperative right ventricular 21 decannulation. 22 Q. (By Ms. Perse) And you have no 23 other answers? That's all I'm asking. 24 MS. KINKOPF-ZAJAC: Objection. 25 He's answered it several times. 0230 1 MS. PERSE: Well, he keeps 2 repeating one answer. 3 MS. KINKOPF-ZAJAC: Because he's 4 only got one answer. 5 MS. PERSE: My question is, is 6 does he have any other? Yes or no? 7 MS. KINKOPF-ZAJAC: He's answering 8 your questions. 9 MS. PERSE: But does he have -- 10 Q. (By Ms. Perse) Are there any other 11 diagnoses you would offer? Yes or no? 12 MS. KINKOPF-ZAJAC: Objection. 13 A. My answer for this patient would 14 be preoperative right ventricular 15 decannulation. 16 Q. (By Ms. Perse) Can we agree that 17 it would be important to have an 18 understanding of the potential causes of right 19 ventricular decannulation, in a patient such 20 as Michael Orra, so that you could administer 21 the appropriate treatment for those different 22 causes? 23 MS. KINKOPF-ZAJAC: Objection. 24 A. I wasn't involved in the 25 decision-making about how to treat his right 0231 1 ventricular decannulation or his preoperative 2 evaluation. 3 Q. (By Ms. Perse) But as a resident 4 in a teaching program, can we agree that it 5 would be important to formulate an 6 understanding of the different potential 7 causes, so that you could render appropriate 8 treatment? 9 MS. KINKOPF-ZAJAC: Objection. 10 A. I wasn't making the decisions about 11 how to treat his right ventricular 12 decannulation. I wasn't involved in his 13 preoperative evaluation. 14 Q. (By Ms. Perse) And I'm not asking 15 specifically about Michael Orra. But I'm 16 asking as a resident in a teaching program, 17 in November of 2005, can we agree it would 18 be important to have an understanding of the 19 differential diagnosis, so that -- and a 20 determination as to the cause of the right 21 ventricular decannulation, such that you could 22 make treatment recommendations or an 23 understanding whatever treatment can be 24 administered? 25 MS. KINKOPF-ZAJAC: Objection. 0232 1 It's -- I'm -- to the hypothetical. I don't 2 even understand it. 3 A. I -- I didn't make treatment 4 recommendations. 5 Q. (By Ms. Perse) Did you understand 6 why doctor -- or Michael Orra was being 7 treated the way he was being treated? 8 A. Well, it doesn't say what the 9 specific treatment was, I don't believe. 10 Q. The operative note goes on to 11 describe that -- 12 A. Correct. 13 Q. -- Michael Orra -- 14 MS. KINKOPF-ZAJAC: Just a minute. 15 Q. -- was started on Milrinone. Do 16 you know -- know what that drug is? 17 A. Sure. 18 Q. And what is that drug? 19 A. It's a phosphodiesterase inhibitor. 20 Q. And what does it do? 21 A. It causes some degree of after-load 22 reduction. And by -- as a sort of secondary 23 consequence, you have some improvement in 24 one's cardiac out-put. 25 Q. Is it specific for treatment of 0233 1 right ventricular decannulation? 2 A. No ma'am. 3 Q. What other treatment is it used 4 for? What other diseases is it used for? 5 A. It can be used to treat patients 6 with hypertension. It can be used to treat 7 patients with global ventricular decannulation. 8 Not necessarily limited to the right 9 ventricle. It could be used to treat 10 patients with heart failure. There is a 11 multitude of -- of -- of uses for it. 12 Q. What is your understanding of why 13 -- what the Milrinone was used for in Michael 14 Orra? 15 A. I didn't initiate this therapy for 16 -- for Michael Orra. 17 Q. Did you write for Michael Orra to 18 have Milrinone in the post-operative period? 19 A. And may I refer to the -- may I 20 refer to the orders here? 21 Q. Orders, sure. 22 A. Correct. Milrinone is on his 23 post-operative orders, and they are signed by 24 me. 25 Q. And so you did order the Milrinone 0234 1 in the postoperative period for Michael Orra, 2 correct? 3 A. Yes. But the Milrinone was 4 started in the operating room. It is a 5 continuation of the -- of the infusions that 6 were started by anesthesia in the operating 7 room. 8 Q. And do you have any idea why you 9 were writing for the Milrinone in Mr. -- in 10 Michael Orra's case? 11 A. Again, it's a continuation of the 12 orders that were -- of the -- of the 13 infusions that the patient was on in the 14 operating room, but he had some right 15 ventricular decannulation. 16 Q. So as -- as a second-year resident 17 writing the orders on -- on Michael Orra, 18 your understanding of why you were writing 19 for Milrinone was? 20 A. Was that he had right ventricular 21 dysfunction in the operating room and this 22 was a continuation of the infusions that were 23 started while the patient was in the 24 operating room. 25 Q. Was the Milrinone used for any 0235 1 other reason besides right ventricular 2 dysfunction? 3 A. Well, again, according to the 4 operative note. It says, however, he had 5 what appeared to be right ventricular 6 dysfunction which was consistent 7 preoperatively. He was started on some 8 intravenous Milrinone and Levophed. 9 Q. What is Levophed? 10 A. And it goes on to say 11 Norepinephrine, which is on the post-operative 12 orders. And it says he was with some 13 improvement in his right ventricular function 14 and hemodynamics. So the therapy worked. 15 Q. But what did it work for? What 16 was it treating? 17 A. Right ventricular decannulation. 18 Q. And we can agree that Michael Orra 19 had right ventricular decannulation 20 post-operatively? 21 A. That's -- well, that's clearly 22 stated in the operative note, that he had 23 some, what appeared right ventricular 24 dysfunction, which was consistent with 25 preoperatively. 0236 1 Q. Do you understand what post-opt -- 2 operatively means? 3 A. Do I understand it? Yes, ma'am. 4 Q. Can we agree that Michael Orra had 5 right ventricular decannulation 6 intra-operatively as well as post-operatively? 7 A. Well, we agree -- I am stating, 8 according to the e operative note, the 9 patient had right ventricular decannulation 10 when he separated from bypass. Therefore, 11 Milrinone was instituted. That's what I'm 12 agreeing to. I'm -- I'm -- I haven't made 13 any comments about his post-operative right 14 ventricular -- right ventricular function. 15 Q. You an -- the reason that you 16 wrote for the Milrinone in the post-operative 17 period was because of his right ventricular 18 decannulation and because it was initiated in 19 the operating room? I believe that's how -- 20 what you answered. 21 A. That's correct. 22 Q. Okay. So when you wrote the order 23 in the post-operative period, it was for 24 right ventricular decannulation, correct? 25 A. That was noted in the operating 0237 1 room and preoperatively, which was the reason 2 the therapy was initiated. 3 Q. Did -- did Milrinone -- did you 4 institute Milrinone intra-operatively? 5 A. I did not. 6 Q. I'm sorry? 7 A. No. I did not. 8 Q. And who ordered the Milrinone? 9 A. I don't -- I don't know who 10 ordered the Milrinone. Usually, those -- those 11 drugs are started by anesthesia. 12 Q. So the operating surgeon or the 13 first assistant have no recommendations -- 14 A. The first -- 15 Q. -- at that point? 16 MS. KINKOPF-ZAJAC: Objection. Go 17 ahead. 18 A. The first assistant would not be 19 giving orders about when to start drugs and 20 what drugs to put the patient on. That's -- 21 that's the -- that falls into the purview of 22 the -- of the staff surgeon and the 23 anesthesiologist. 24 Q. So the Milrinone was ordered either 25 by the staff surgeon, Dr. Sabik, or the 0238 1 anesthesiologist in this case? 2 A. I don't -- I said I do not know 3 who ordered the Milrinone. I do not know 4 who ordered the Milrinone. What I said was 5 that usually it is started by anesthesia. 6 Q. But you also said that it could be 7 ordered by the staff surgeon, correct? 8 A. The staff surgeon can ask for it, 9 definitely. 10 Q. Is it the staff surgeon's 11 responsibility to make sure that the patient's 12 heart is functioning sufficiently that they 13 can come off the operating room table? 14 MS. KINKOPF-ZAJAC: Objection. If 15 you understand that. 16 A. Come off the operating room table? 17 Q. (By Ms. Perse) Yes. 18 A. Well, my -- my answer to that 19 would be that the -- my experience with the 20 staff surgeons has been that the -- they 21 ensure that the patient has good function to 22 separate from bypass, initially. I mean, 23 that would be the step before you -- before 24 you leave the operating room. 25 Q. So when the staff surgeon leaves 0239 1 the room, it is your responsibility as the 2 first assist -- assistant to make a 3 determination as to whether the patient is 4 stable to leave the operating room. True? 5 MS. KINKOPF-ZAJAC: Objection. 6 A. It is in part my decision. 7 Q. (By Ms. Perse) Who else is 8 responsible for that decision? 9 A. Anesthesia. 10 Q. Was there any discussion in this 11 case about Michael Orra leaving the operating 12 room? 13 A. Well, again, according to the 14 operative note, there did not appear to be 15 any question about the patient's ability to 16 leave the operating room. It says that he 17 weaned from cardiopulmonary bypass without 18 difficulty. However, he had what appeared to 19 be right ventricular decannulation, which was 20 consistent with preoperatively. He was 21 started on some intravenous Milrinone and 22 Levophed with some improvement in his right 23 ventricular function and hemodynamics. 24 Q. When did Dr. Sabik leave the room? 25 A. I -- I don't remember specifically 0240 1 when he left the room. 2 MS. KINKOPF-ZAJAC: Hello. 3 Q. (By Ms. Perse) Can you tell me 4 when Michael Orra was -- was decannulated? 5 A. Do you -- you mean -- 6 Q. There is no mention of that in the 7 operative note, correct? 8 A. It doesn't say specifically. But 9 it does say he weaned from cardiopulmonary 10 bypass without difficulty. 11 Q. But, again, it doesn't tell us 12 when he was decannulated, correct? 13 A. It does not say specifically. 14 Q. And you don't have an independent 15 recollection of this procedure, correct? 16 A. No, ma'am. 17 Q. Do you know if you declan -- 18 cannulated? 19 A. I don't remember. 20 Q. Did you dictate any operative note 21 on this procedure? 22 A. No, ma'am. 23 Q. Have you ever seen an unrevised 24 copy of the operative note? 25 MS. KINKOPF-ZAJAC: Objection. 0241 1 Asked and answered. 2 A. No, ma'am. 3 Q. (By Ms. Perse) In your experience 4 as a resident at the clinic, tell me, did 5 you ever see unrevised operative notes? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. I don't recall seeing unrevised 8 operative notes. I -- I am not -- 9 Q. Your understanding of what an 10 unrevised operative note is? 11 A. I'm not sure what the terminology 12 -- I am not sure what the terminology means. 13 MS. KINKOPF-ZAJAC: You guys need 14 to talk one at a time. He is still answering 15 your question, and you're starting on 16 something else. 17 MS. PERSE: I -- I apologize. 18 MS. KINKOPF-ZAJAC: So let him 19 finish his answer and -- 20 MS. PERSE: Yeah. I can't hear. 21 And, again, I didn't intend -- I thought he 22 had answered. I'm sorry. 23 A. I -- I -- I was saying I'm -- 24 I'm not sure what the terminology means 25 exactly. So I -- I don't -- I don't know 0242 1 exactly what the term -- what they are 2 referring to when they say that. 3 Q. (By Ms. Perse) What does revised 4 mean? 5 A. What does revised mean? 6 Q. Yes. 7 MS. KINKOPF-ZAJAC: Objection. 8 A. You just want a definition of 9 revised? 10 Q. (By Ms. Perse) Well, in the 11 context of the operative note for Michael 12 Orra, tell me what your understanding of 13 revised would mean? 14 A. Well, I -- I didn't -- yeah. 15 MS. KINKOPF-ZAJAC: Objection. Go 16 ahead. 17 A. I didn't do the operative note for 18 Michael Orra. I don't know what they mean. 19 Q. (By Ms. Perse) Yes. In -- in con 20 -- in -- in your practice, at the clinic, 21 had you ever seen a revised operative note 22 before? 23 MS. KINKOPF-ZAJAC: Objection. 24 A. Well, I didn't have a practice at 25 the clinic. 0243 1 Q. (By Ms. Perse) When you were a 2 resident at the clinic, -- 3 A. Yes. 4 Q. -- had you ever seen a revised 5 operative note before? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. Again, I don't know what the 8 terminology means. I've -- I've -- I've seen 9 operative notes. Sure. I have one in front 10 of me. 11 Q. (By Ms. Perse) No. And, again, I 12 -- I'm not -- I know it's been a long 13 morning, but you need to -- to listen to my 14 question. 15 And my question was, number one, 16 have you seen, at -- during your residency at 17 the clinic, had you ever seen a revised 18 operative note before? 19 MS. KINKOPF-ZAJAC: Objection. 20 Asked and answered. 21 A. No. 22 Q. (By Ms. Perse) Yes or no? 23 A. No, ma'am. 24 Q. So this would be the first time 25 that you would have seen a revised operative 0244 1 note? 2 MS. KINKOPF-ZAJAC: Objection. I 3 think he said he doesn't know what is meant 4 by the word revised. 5 MS. PERSE: No. I didn't ask -- 6 I'm not asking the meaning of. 7 Q. (By Ms. Perse) I'm asking if he 8 ever saw one? 9 A. Um -- 10 Q. And we've established that this one 11 is a revised op note? 12 A. I don't think we have established 13 that. Have we established that? 14 Q. Well, it says, revised. And I'm 15 trying to figure out what the term -- that 16 means. 17 A. What says revised is -- 18 MS. KINKOPF-ZAJAC: You guys. 19 THE WITNESS: I'm sorry. I 20 apologize. 21 MS. KINKOPF-ZAJAC: Okay. Go 22 ahead, Jessica. 23 Q. (By Ms. Perse) So is this the 24 first time that you have seen the revised -- 25 the terminology revised op note or revised on 0245 1 a transcribed procedure note? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. Well, this is the first time I've 4 seen this operative note. So is this the 5 revised copy? 6 Q. (By Ms. Perse) I'm not speaking of 7 this note, per se. I'm asking is this the 8 first time you've ever seen a revised 9 operative note generated from the Cleveland 10 Clinic? 11 MS. KINKOPF-ZAJAC: Objection. 12 A. I can't answer that question. I'm 13 asking -- I'm asking, is this the revised 14 copy? I mean, I don't know. Is this the 15 revised copy? 16 Q. (By Ms. Perse) Again, since we are 17 working long-distance here. I'm looking at 18 an operative note. And underneath the times 19 of dictation and transcription? 20 A. True. 21 Q. There is a line that is identified 22 as revised. Do you have that page in front 23 of you? 24 A. Yes. 25 Q. And what -- when you're looking at 0246 1 that, is that the first time you've ever seen 2 a -- that terminology on a procedure note, 3 generated from the Cleveland Clinic? 4 MS. KINKOPF-ZAJAC: Objection. Go 5 ahead. If you answer -- if you know. 6 A. I honestly don't remember seeing 7 this terminology, but -- 8 Q. (By Ms. Perse) No. Right -- 9 right. Okay. 10 Now the system that was in place 11 at the clinic -- are you familiar with the 12 computer system? 13 A. I -- I'm familiar with the 14 computer system. 15 Q. And what kind of computer system 16 was that? 17 MS. KINKOPF-ZAJAC: In 2005? 18 MS. PERSE: 2005. 19 MS. KINKOPF-ZAJAC: If you 20 remember. Go ahead. 21 A. I mean, what -- what specifically 22 are you asking? I mean, what kind of software 23 was used? I don't remember those details. 24 Q. (By Ms. Perse) Was -- was the 25 operate -- I am sorry. Was the medical 0247 1 record system, computerized system known as 2 EPIC in 2005? 3 A. I do believe it -- that -- that 4 we had EPIC. 5 Q. I apologize. I didn't hear your 6 answer. 7 A. I -- I said I do believe we had 8 EPIC pick in 2005. I don't -- I don't -- I 9 -- I -- I honestly do not remember 10 specifically what the software was that ran 11 the -- the medical record. Most of the 12 chart was -- was a paper chart. 13 Q. Did you ever have occasion to 14 review an operative note in the computerized 15 system, when you were a resident in 2005? 16 A. No. I -- I wouldn't -- I 17 wouldn't be doing that. 18 Q. And why is that? 19 A. Because I didn't dictate the 20 operative notes. 21 Q. So in 2005, as a second-year 22 resident, you never dictated operative notes? 23 A. No, ma'am. That was the re -- 24 the responsibility of the staff surgeon. We 25 didn't dictate op notes. 0248 1 Q. Did you have any familiarity with 2 EPIC in terms of putting orders in or writing 3 any kind of notes in the records? 4 A. No. I didn't write noes in EPIC. 5 I didn't write orders in EPIC. 6 Q. Did you access records from EPIC? 7 A. You could see old records from 8 EPIC. Sure. But I -- I -- I never -- I 9 always wrote in the chart. I never had 10 access to EPIC to put notes in the computer. 11 Q. Did you have an EPIC password? 12 A. Actually, no. I don't think that 13 I did. I am pretty sure I didn't. 14 Q. So you would have -- would it be 15 fair to say you had no access to the records 16 that were generated in EPIC? 17 MS. KINKOPF-ZAJAC: Objection. I 18 don't think that's what he said. Go ahead. 19 A. What -- what I said was, I did 20 not write notes in EPIC. I did not write 21 orders in EPIC. I certainly have -- have 22 seen and been in EPIC before through someone 23 else's password. We had nurse practitioners 24 that have access to that sort of thing. But 25 we just -- as residents, that wasn't our -- 0249 1 we didn't -- we didn't do that. We wrote in 2 the paper chart. 3 Q. Okay. Is it possible that Michael 4 Orra's right heart failure was caused by 5 inadequate myocardial pro -- protection? 6 MS. KINKOPF-ZAJAC: Objection as to 7 the possibility. And the fact that he is not 8 an expert. But if you can tell. 9 A. I don't know what the cause of his 10 right heart decannulation was except that he 11 had it preoperatively/. 12 Q. (By Ms. Perse) And I'm not asking 13 -- did he require Milrinone post -- 14 preoperatively? 15 A. I don't know. I didn't see him 16 preoperatively. 17 Q. When you entered the operating 18 room, do you have any reason to believe that 19 doctor -- Michael Orra required Milrinone at 20 the start of the procedure -- 21 MS. KINKOPF-ZAJAC: Objection. 22 Q. (By Ms. Perse) -- when you -- he 23 was under your care? 24 A. I did not see Dr. Orra pre-or -- 25 preoperatively. 0250 1 Q. At the start of the procedure, 2 when he was in the operating room, when you 3 were the operating surgeon, when Dr. Sabik 4 was not in attendance, was Michael Orra, at 5 any time, on Milrinone? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. I do not recall that he was on 8 Milrinone. 9 Q. (By Ms. Perse) Can we agree that 10 as a second-year resident, you would know 11 that inadequate myocardial protection would be 12 a potential cause of right heart failure in 13 an ASD repair? 14 MS. KINKOPF-ZAJAC: Objection. Did 15 he know that as a second-year resident. 16 A. I don't know what the cause of Dr. 17 Orra's right ventricular dysfunction was. I 18 know that he had it preoperatively. 19 Q. (By Ms. Perse) And, in general, 20 not with -- in Michael Orra's case 21 specifically. But in a case -- a 22 hypothetical case, where a patient was 23 undergoing an open ASD repair. Can we agree 24 that one of the potential causes of the right 25 heart failure could be inadequate myocardial 0251 1 protection? 2 MS. KINKOPF-ZAJAC: Objection to 3 the hypothetical. If you can answer. 4 A. I don't know what the cause of Dr. 5 Orra's right ventricular decannulation was, 6 except that he had it preoperatively. 7 Q. (By Ms. Perse) If Michael Orra had 8 right ventricular dysfunction, and Dr. Sabik 9 has left the room, would -- why was not a 10 TEE or transesophageal echo performed before 11 Michael Orra left the operating room? 12 MS. KINKOPF-ZAJAC: Objection. 13 There is a lot of different questions in 14 there. 15 A. What -- what is the question? 16 MS. PERSE: Can you read it back, 17 court reporter? 18 (Question read by the court 19 reporter.) 20 A. Well, I don't -- I don't -- I 21 don't have an answer for that. I don't -- 22 I'm not -- I'm not sure why -- why - why 23 that conclusion is being made. I don't -- I 24 don't really have an answer for that 25 question. 0252 1 Q. (By Ms. Perse) Can we agree that 2 it was -- it is unusual for two inotropes to 3 be required in the post-operative period or 4 to get the patient off of bypass following an 5 ASD repair? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. No. We cannot agree on that. 8 Q. (By Ms. Perse) Can we agree that 9 it would be unusual to require Milrinone and 10 Levophed in a patient that did not require 11 the -- those drugs preoperatively? 12 MS. KINKOPF-ZAJAC: Objection. Go 13 ahead. 14 A. Again, no. We cannot agree on 15 that. 16 Q. (By Ms. Perse) Can you tell me who 17 closed Michael Orra's chest? 18 A. Referring specifically to what -- 19 to what part of closure of his chest? 20 Q. Well, why don't we -- we why don't 21 you tell me what part of the closure you 22 performed on Michael Orra? 23 A. I can't tell you specifically which 24 part I -- I -- I closed. 25 Q. I'm sorry. What? 0253 1 A. I can't tell you specifically which 2 part I closed. 3 Q. Who else would have been 4 responsible for the closure? 5 A. Dr. Sabik. 6 Q. When does closure occur after 7 decannulation? 8 A. Are you referring in -- in general 9 or to this particular patient? 10 Q. Michael Orra. How long after 11 decannulation would closure have taken place? 12 A. I -- I can't give you a number, 13 how long it would -- how long it took. I 14 -- I -- I don't have any indication of how 15 long it took. 16 Q. Tell me when -- at what point in 17 time would the Milrinone and Levophed have 18 been administered after decannulation? 19 MS. KINKOPF-ZAJAC: Objection. 20 A. I don't know specifically. It 21 just says that it was started. 22 Q. (By Ms. Perse) Is it fair to say 23 that the Milrinone and the Levophed were 24 administered after the decannulation? 25 MS. KINKOPF-ZAJAC: Objection. 0254 1 A. I can't say that. The -- the 2 operative note doesn't reflect that. I don't 3 know specifically when it was started. I 4 can't answer that. 5 Q. (By Ms. Perse) And the Milrinone 6 and the Levophed were administered by 7 anesthesiology, not the cardiopulmonary 8 profusion team? 9 MS, KINKOPF-ZAJAC: Objection. 10 A. I can't answer that either. 11 MS. KINKOPF-ZAJAC: How are we 12 doing time wise? 13 MS. PERSE: I understand that -- 14 I'm just trying to -- trying to get through 15 here. I know that you are on some time 16 constraints here. 17 MS. KINKOPF-ZAJAC: So how are we 18 doing? 19 MS. PERSE: I can't say that -- 20 say for sure, but I'm aiming to be done in 21 the next 45 minutes. 22 MS. KINKOPF-ZAJAC: That would be 23 good. Thank you. 24 Did we lose you? 25 MS. PERSE: No. No. I'm just 0255 1 reviewing my notes here. I apologize. 2 Q. (By Ms. Perse) Would you have any 3 reason to disagree that Dr. Sabik was present 4 through cardiopulmonary bypass to 5 decannulation? 6 A. Would I have any reason to 7 disagree what, again? I am sorry. I didn't 8 completely hear that. 9 Q. That Dr. Sabik was present during 10 the case between cardiopulmonary bypass through 11 decannulation? 12 A. Yes. I would have a reason to 13 disagree with that. 14 Q. Tell me what your reason is. 15 A. Well, the operative note reflects 16 that the patient had right ventricular 17 decannulation, which was consistent with 18 preoperatively. And that Milrinone and 19 Levophed was started. So I would say that 20 Dr. Sabik probably stayed longer. 21 Q. Why does the fact that there was 22 right ventricular decannulation lead you to 23 conclude that Dr. Sabik stayed longer? 24 MS. KINKOPF-ZAJAC: Objection. I 25 don't think that's what he said, but go 0256 1 ahead. 2 A. Well, to ensure that the therapy 3 was working and that the patient was doing 4 well. 5 Q. (By Ms. Perse) Was the pa -- was 6 Michael Orra's position changed, at all, 7 during the operation? 8 A. I -- I don't re -- I don't -- I 9 honestly don't remember what position the 10 patient was put in and what changes might 11 have been made during the operation. 12 Q. And do you know if the operative 13 note indicates that the patient's positioning 14 was changed at any point? 15 A. We read the operative note. I 16 don't remember reading anything to that affect 17 in the operative note. 18 Q. Do you know if the operative field 19 was, at all, flooded with any C0 2 gas or 20 anything like that? 21 A. I can't comment specifically about 22 that if it's not in the operative note. 23 Q. So if it's not in the operative 24 note and you don't have any recollection, do 25 you know -- did it occur? 0257 1 MS. KINKOPF-ZAJAC: Objection. 2 A. Well, my -- 3 MS. KINKOPF-ZAJAC: I think he 4 just said it is not in the operative note. 5 But go ahead. 6 A. It's -- I don't have any specific 7 recollection. And the operative note -- the 8 operative note, we've been through. I don't 9 have any other answer for that question. 10 Q. (By Ms. Perse) Now in the post-op 11 period, did you take care of Michael Orra? 12 A. Overnight. First operative -- the 13 first operative night. 14 Q. And do you know when Michael Orra 15 left the operating room? 16 A. I'm sorry. Excuse me. I was 17 yawning. Excuse me. 18 I don't remember the exact time 19 that we left the operating room. 20 Q. Can you look at the records to 21 make that determination? 22 A. I'm not sure that any other 23 records that I was involved in would 24 specifically say what time he left the 25 operating room. I -- I -- I can't tell you 0258 1 what time he left the operating room. 2 Q. I'm looking at a note entitled 3 Cardiovascular Operative Notes, and there's a 4 picture of a heart on it? 5 A. Correct. 6 Q. I see a -- a signature on it. 7 It's dated November 30th, '05? 8 A. Uh-huh. 9 Q. And there is a signature on the 10 bottom, right-hand corner. Can you locate 11 that record for me? 12 A. I have it. 13 MS. PERSE: I'm going to ask that 14 that be marked as an exhibit. And I guess 15 that would be -- it's a continuation. So 16 it's Exhibit C. I think we were going by 17 letters in the last one, but it would be the 18 first exhibit of this Part II. 19 MS. KINKOPF-ZAJAC: Are we 20 providing your exhibits? 21 MS. PERSE: Pardon? 22 MS. KINKOPF-ZAJAC: Are we 23 providing your exhibits? 24 MS. PERSE: Well, I can copy them 25 and provide them to the reporter. I just 0259 1 want to make sure we are talking about the 2 same record. 3 MS. KINKOPF-ZAJAC: Okay. 4 Q. (By Ms. Perse) Since we're 5 long-distance, I just want to ask Dr. Bryant 6 to read his entries. Is -- am I correct, 7 those your entries on this page? 8 A. That is correct. 9 Q. Can you read your entries for the 10 record? 11 A. Do you want me to just read the 12 entire note? 13 Q. Yeah. What you've recorded. 14 MS. KINKOPF-ZAJAC: Just read slow, 15 so we don't drive Judy crazy. Okay? 16 A. Date, November 30th, 2005. 17 Preoperative diagnosis. Secundum ASD. 18 Post-operative diagnosis the same. Operation. 19 Median sternotomy. Pericardial patch. Secundum 20 ASD repair. Surgeon, Sabik. Assistant, R. 21 Bryant. Anesthesia, Duncan. Tubes. Two 22 mediastinal. One right pleural. 23 Q. Can I ask you, is that a two or 24 a three next to mediastinal? 25 A. That would be two. 0260 1 Q. All right. Sorry to interrupt. 2 A. One right pleural. Postop 3 condition. On Milrinone, Levo. Findings. 4 Pulmonary hypertension by palpation after ASD 5 closure with poor RV initially. This 6 improved with Milrinone. 7 Q. Can you explain to me your entry 8 about pulmonary hem -- hypertension by pal -- 9 palpation? 10 A. Sure. It means that Dr. Sabik 11 placed his fingers on the PA, and it felt 12 like the blood pressure was higher than 13 usual. 14 Q. And what is the significance of 15 that? 16 A. That the blood pressure is higher 17 than usual. 18 Q. What causes the blood pressure to 19 be higher than usual? 20 MS. KINKOPF-ZAJAC: Objection. 21 A. Well, pulmonary hypertension. And, 22 in this case, a left to right shunt. 23 Q. (By Ms. Perse) Do you -- is there 24 any indication in the note as to when this 25 palpation of the pulmonary artery occurred? 0261 1 A. No, ma'am. 2 Q. Do you have any understanding of 3 when the palpation of the pulmonary artery 4 occurred? 5 A. No, ma'am. 6 Q. Do you comment in the preoperative 7 diagnosis about any right ventricular 8 decannulation? 9 A. In the preoperative diagnosis? I 10 did not mention that in this note. No. I 11 did not. But I didn't see the patient 12 preoperatively either. 13 Q. But when did you write this note? 14 A. After the operation. 15 Q. So it was your assessment that, 16 post-operatively, he required Milrinone and 17 Levophed, correct? 18 A. Yes. That's consistent with the 19 operative note. 20 Q. I'm just asking about this 21 procedure note? 22 A. Correct. 23 Q. And you described the RV function 24 as poor in your findings. Can you quantify 25 for me what you mean by poor? 0262 1 A. Not normal. 2 Q. Who is Dr. Mart -- I'm going to 3 spell it. M-A-R-T-S-I-N-K-A-I-C-H? 4 A. I don't know. Can you spell it 5 again? 6 Q. M-A-R-T-S-I-N-K-A-I-C-H? 7 A. I don't know. 8 Q. I see his signature on a 9 cardiothoracic anesthesia ICU admission note. 10 A. I am sorry. I -- I'm not going 11 to be able to comment about anesthesia's 12 note. 13 Q. I'm just wondering about who the 14 person was? That's all. 15 A. I don't know. 16 Q. Did you write any other notes? 17 A. I did. 18 Q. Okay. I'm looking at a progress 19 note from 12-1 with no time on it. That 20 starts off with the indication CTS. 21 A. Yes. 22 Q. And there is a signature in the 23 lower right side of the page, about a little 24 bit more than halfway down. 25 A. Uh-huh. 0263 1 Q. Can you see -- are you -- you 2 looking at that page? 3 A. I am. 4 Q. Is that a progress note? 5 A. That is a progress note. 6 Q. And am I correct that that's your 7 signature? 8 A. That is correct. 9 Q. And did you complete that note? 10 A. Yes, ma'am. 11 MS. PERSE: I'm going to ask you 12 -- I'm going to -- I'll provide this to the 13 reporter as the next exhibit, which would be 14 two for today's deposition. 15 Q. (By Ms. Perse) I'm going to ask 16 you, can you read your entries in the record 17 for me? 18 A. So it starts out, intermittent 19 episodes of hypotension. Responded well to 20 volume. Then there are the vital signs. 37.5 21 was his temperature. His heart rate was 96. 22 Blood pressure, 83 over 54. He was 23 intubated. The vent settings were SPCV, 24 which is the pressure support. He was on 50 25 percent FI02, 10 peep/8 pressure support. 0264 1 The eyes and nose, 3487 over 3070. His 2 chest tube output was 400 cc's with 600 cc's 3 from his right chest tube. His breath sounds 4 were equal. He was in sinus rhythm. His 5 abdomen was soft. 6 Q. Okay. Let me just stop you there. 7 But does -- can we go back up to the chest 8 tube output? 9 A. Sure. 10 Q. How much did you say was out of 11 the right chest? 12 A. 600. 13 Q. And the other quantify of 4000. 14 Was that from the -- the two mediastinal 15 tubes then? 16 A. Probably. I don't say it 17 specifically, but that's probably where it was 18 from. 19 Q. Is there any time on this note? 20 A. No. 21 Q. Do you have any way of knowing 22 when you wrote this note? 23 A. Probably in the morning. 24 Q. And what time in the morning? 25 A. I can't tell you specifically, but 0265 1 I'm an early riser. So I'm sure it was 2 pretty early. 3 Q. Do you know what day of the week 4 this was? 5 A. That would be December 1st. 6 THE VIDEOGRAPHER: Excuse me. We 7 have two minutes. 8 Q. (By Ms. Perse) Why don't you go 9 ahead and continue the -- reading your 10 entries? 11 A. Okay. So assessment. Status post 12 ASD closure. Labile. No hard signs of 13 tamponade. Good UOP, which is an acronym for 14 urine output. Cardiac index greater than 2.5 15 but high chest tube output. And it says, 16 plan, check echo. Continue with Levophed and 17 Milrinone. 18 Q. Was your plan to continue the 19 Levophed and Milrinone at that point in time? 20 A. Yes. 21 Q. And why were you continuing the 22 Levophed and Milrinone? 23 A. Well, he -- he had some issues 24 with his blood pressure overnight. He had 25 some volume. And, usually, we want to keep 0266 1 those going until the patient is a little bit 2 more stable. 3 Q. But did you have any idea what you 4 were treating? 5 MS. KINKOPF-ZAJAC: Objection. 6 A. Did I have any idea what I was 7 treating? I was continuing the therapy that 8 the patient was started when he was in the 9 operating room. 10 Q. (By Ms. Perse) I understand that 11 you were contri -- continuing the therapy. 12 But did you know what you were treating? 13 MS. KINKOPF-ZAJAC: Objection. One 14 minute left. 15 A. Well, as we discussed, the therapy 16 was started because the patient had right 17 ventricular decannulation while he was in the 18 operating room. 19 MS. KINKOPF-ZAJAC: Jessica, we've 20 got less than a minute left on the video. 21 Q. (By Ms. Perse) Did -- 22 MS. KINKOPF-ZAJAC: Did you hear 23 me? 24 MS. PERSE: Yes, I did. I was 25 going to try to sneak in one more question, 0267 1 but let's take a quick break because I -- 2 again, I'm trying to get done by noon. 3 THE VIDEOGRAPHER: We're off the 4 record. It is 10:35 a.m. 5 (Recess taken from 10:35 a.m. until 6 10:38 a.m.) 7 THE VIDEOGRAPHER: We are on the 8 record. It is 10:38 a.m. 9 Q. (By Ms. Perse) Okay, Doctor. 10 We're reviewing the -- your progress note 11 from December 1, '08. Did you write any 12 other notes in Dr. Sabik's chart? 13 MS. KINKOPF-ZAJAC: Dr. Orra's 14 chart? 15 MS. PERSE: Sorry about that. 16 Q. (By Ms. Perse) Michael Orra's 17 chart? I apologize. 18 A. No, ma'am. 19 Q. And I want to be specific. Any 20 progress note? 21 A. No, ma'am. 22 Q. Were you at all responsible for 23 Michael Orra's care after you completed that 24 progress note of December 1? 25 A. No, ma'am. 0268 1 Q. Is it fair to say you were off 2 Dr. Sabik's service -- 3 MS. KINKOPF-ZAJAC: Doctor -- oh, 4 sorry. Excuse me. Go ahead. 5 MS. PERSE: Thought you caught me 6 there. 7 MS. KINKOPF-ZAJAC: I did think I 8 caught you there. 9 MS. PERSE: I thought you caught 10 me, too. 11 Q. (By Ms. Perse) Were you on -- 12 were you off of Dr. Sabik's service -- 13 MS. KINKOPF-ZAJAC: Did you 14 understand the question? 15 A. You mean -- 16 Q. (By Ms. Perse) -- and note? 17 A. -- off -- off as in -- in what 18 sense? You mean off after this case or just 19 not on his service at the time? 20 Q. I'm sorry. I did not hear the 21 question. 22 A. You mean -- you mean not on his 23 service at the time that the case was done? 24 Q. Yeah. Were you not on Dr. Sabik's 25 service after this December 1 note? 0269 1 A. I don't -- no. I don't think 2 that I was on his service, at all. I think 3 I just helped him with this case is my sense 4 of the situation. 5 Q. So you were not responsible for 6 Michael Orra, beyond what you participated in, 7 in the operating room until the conclusion of 8 this note. Correct? 9 A. Cor -- correct. 10 Q. Tell me -- you described Michael 11 Orra as having hypotension. What was the 12 significance of the hyper -- hypotension? 13 A. What was the significance of it? 14 Well, the blood pressure was lower than we 15 would typically see for someone of his age. 16 But he did not appear to be adversely 17 affected by it at the time. 18 Q. What does it mean when hypotension 19 is responsive to volume? 20 A. That his blood pressure improved. 21 Q. So we agree that this implies that 22 doctor -- Michael Orra had good left 23 ventricular function? 24 MS. KINKOPF-ZAJAC: Objection. Go 25 ahead. If you can answer it. 0270 1 A. You can assume that. But what was 2 meant was that he had improvement in his 3 blood pressure by giving volume. 4 Q. (By Ms. Perse) I apologize, Doctor. 5 I didn't hear your answer. 6 A. I said you can assume that. But 7 what -- what was meant by the statement was 8 that his blood pressure improved when volume 9 was given. It wasn't in reference to his LV 10 function, specifically. 11 Q. Under your assessment. You 12 described that Michael Orra was labile and 13 had no hard signs of tamponade. Is it fair 14 to say you were considering tamponade in your 15 diag -- differential diagnosis? 16 MS. KINKOPF-ZAJAC: Objection. Go 17 ahead. 18 A. Absolutely. 19 Q. (By Ms. Perse) And why was that? 20 A. Well, because he had lower blood 21 pressure. 22 Q. Is that the only reason? 23 A. Hum -- 24 MS. KINKOPF-ZAJAC: Objection. Go 25 ahead. 0271 1 A. No. Because drainage from his 2 chest tube was -- as -- as indicated, 400 3 cc's total from the -- from the mediastinals 4 and 600 cc's from the right chest tube. 5 Q. (By Ms. Perse) I -- I need you to 6 speak up because I catch every other word 7 there. 8 A. So I said that wasn't the only 9 consideration. It was that the low blood 10 pressure, in addition to the chest tube 11 drainage. 12 Q. And why did you recommend to check 13 an echo? 14 A. To evaluate for a tamponade. 15 Q. Was that the only reason? 16 MS. KINKOPF-ZAJAC: Objection. 17 A. That was the reason that the echo 18 was ordered. 19 Q. (By Ms. Perse) And what kind of 20 echo were you requesting? 21 A. Transthoracic. 22 Q. Did you speak to anybody about 23 these findings that you wrote in this note? 24 A. Did I call anyone, specifically? 25 I don't recall that being the case. 0272 1 Q. Yeah. And I -- I am -- I am 2 sorry to interrupt you. You may not be 3 done, but you are breaking in and out. 4 A. No. I say I don't recall that 5 being the case that I called anyone 6 specifically about it. 7 Q. Can we agree you didn't write any 8 confirmation that you discussed the -- then 9 the findings in the note with anybody? 10 A. No. I -- I don't -- I don't say 11 in the note that I discussed this with 12 anyone. 13 Q. Do you have any independent 14 recollection of talking with Dr. Sabik after 15 the operation? 16 A. I -- I don't remember talking to 17 him over -- overnight about this case. 18 Q. Do you have any recollection of 19 talking to Dr. Sabik when Michael Orra was in 20 the recovery room? 21 A. Well, he would have gone directly 22 to the intensive care unit. I don't -- I 23 don't remember specifically. I don't remember 24 that specifically. No, ma'am. 25 Q. Tell me, when you are covering a 0273 1 service or say on call, what -- from what 2 time to what time does your on-call schedule 3 go? 4 A. Usually -- 5 MS. KINKOPF-ZAJAC: Obviously at 6 this particular time, right? 7 THE WITNESS: Yeah. 8 MS. KINKOPF-ZAJAC: November of 9 '05? 10 MS. PERSE: And, actually, yes. 11 November 30th, '05 to -- 12 MS. KINKOPF-ZAJAC: Or whatever. 13 A. In general, from -- yeah. 7:00 to 14 7:00. 15 Q. (By Ms. Perse) Do you believe it 16 went -- it would have gone from 7:00 a.m. to 17 7:00 a.m. the following day? 18 A. No. 7:00 -- 7:00 p.m to 7:00 19 a.m. 20 Q. I'm sorry. I didn't hear you. 21 A. 7:00 p.m. to 7:00 a.m. 22 Q. So your call would have started on 23 November 30th, 2005 at 7:00 p.m.? 24 A. Correct. 25 Q. Until 7:00 a.m. on December 1, 0274 1 2005. Correct? 2 A. Yes, ma'am. 3 Q. Correct? 4 A. Correct. 5 Q. Do -- in -- in general, in the 6 fall of 2005, how would you communicate the 7 status of patients to the next call team? 8 A. Well, the general set-tup was that 9 it wasn't communicated to the next call team. 10 It was communicated to the primary team when 11 they came in the next morning. 12 So at -- at -- at the Cleveland 13 Clinic, there are the nurse practitioners and 14 anesthesiologists that cover each one of the 15 separate ICUs. So information is relayed 16 about patients in that particular unit to 17 that person who is covering the unit, in 18 addition to the residents that are responsible 19 for the service that that patient is on. 20 Q. And who would be the nurse 21 practitioner on the service taking care of 22 Michael Orra? 23 A. Well, I -- I don't remember who it 24 was, at the time, quite frankly. 25 Q. Do you remember having a 0275 1 communication with a nurse practitioner? 2 A. I don't remember the specific 3 conversation. 4 Q. My question was, do you remember 5 having a conversation? 6 A. I do not remember specifically the 7 conversation. 8 Q. But did you have a conversation 9 with a nurse practitioner about Michael Orra? 10 A. Well, I can say in general our -- 11 our routine is to speak to the nurse 12 practitioners and to the primary team, but I 13 don't -- I don't remember those conversations 14 specifically. But that is usually what we 15 would do. 16 Q. So you do not remember having a 17 conversation? 18 A. I do not remember specifically the 19 conversation with the nurse practitioner or 20 with the primary team that was taking care of 21 the patient at the time. But, I'm pretty 22 sure that we had a conversation about this 23 patient. I don't remember specifically the 24 conversation. 25 Q. And how are you sure that you had 0276 1 a conversation? 2 A. Well, because that is my personal 3 routine and the routine of how we did things 4 at the clinic is to relay information that we 5 know of patients during the night to the team 6 that was coming on to take care of the 7 patient. 8 Q. And you don't remember who you 9 would have spoken to? 10 A. I don't -- I don't remember who -- 11 who -- I don't remember who it was at the 12 time. 13 Q. Or even how many people you would 14 have talked to? 15 A. No. 16 Q. Is that true? 17 MS. KINKOPF-ZAJAC: Keep your voice 18 up, Roosevelt. She can't hear you. 19 A. Is that -- is that true, how many 20 people? 21 Q. (By Ms. Perse) Yeah. I -- 22 A. I don't remember how many people. 23 No. 24 Q. I heard you say that there was -- 25 there would have potentially been a nurse 0277 1 practitioner -- 2 MS. KINKOPF-ZAJAC: He said no. 3 A. I said no. I don't remember how 4 many people. 5 Q. (By Ms. Perse) If any? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. I don't remember how many people. 8 Q. (By Ms. Perse) Do you remember 9 having a conversation with anyone? 10 MS. KINKOPF-ZAJAC: Objection. 11 Asked and answered. Tell her again. 12 A. Again, I am sure that I had a 13 conversation with the primary team that was 14 taking care of the patient and with the 15 practitioner that was covering that unit. 16 But I do not remember the conversation 17 specifically or who the person was at the 18 time. It's three years ago. 19 Q. (By Ms. Perse) Do you know if Dr. 20 Sabik saw Michael Orra in the period from 21 7:00 p.m. to 7:00 a.m.? 22 A. I can't -- again, I can't tell you 23 exactly. I can tell you what -- what I know 24 of Dr. Sabik. I can't tell you that he 25 actually was there. But, I mean, usually he 0278 1 sees his patients after they arrive in the 2 ICU. 3 Q. But you did not see Dr. Sabik? 4 A. I can't say specifically for this 5 situation. I can just tell you what I know 6 of him, and that -- that his -- his routine 7 is to see patients that he's operated on in 8 the intensive care unit after they arrive 9 from the operating room. 10 Q. Did doctor -- or Michael Orra have 11 an atrial pacemaker placed? 12 A. An atrial pacemaker? 13 Q. Yes. 14 A. What do you mean? 15 Q. Did he have pacer wires placed 16 after or during the operation? 17 A. May I refer back to the -- to the 18 operative note, please? 19 Q. Sure. 20 A. I -- I don't see it specifically 21 mentioned. 22 MS. KINKOPF-ZAJAC: It's in the 23 last sentence. 24 THE WITNESS: Pardon? Oh, I'm 25 sorry. Hold on. Hold on one second. 0279 1 Q. (By Ms. Perse) Who put in the 2 atrial pacing wires? 3 A. I may be missing something. 4 Yes. I'm sorry. So hemostasis 5 was obtained. Train -- chest drains and 6 pacing wires were placed. And the would was 7 closed in the standard -- so, yes. He had 8 epicardia pacing wires placed. 9 Q. (By Ms. Perse) And who typically 10 puts the pacing wires in? 11 A. All that stuff is done prior -- 12 usually is done before the staff surgeon 13 leaves the room. 14 Q. Do you have any recollection of 15 who put in the pacing wires in Michael Orra? 16 A. So the staff surgeon usually before 17 he leaves the room. 18 Q. But, again, I'm asking you, in 19 Michael Orra's case, is there anything in the 20 record that indicates who put in the pacing 21 wires? 22 A. No, ma'am. 23 Q. I'm looking at the orders, the 24 physician's orders for November -- the 25 handwritten order, not the standing orders -- 0280 1 for November 30th, 2005. 2 A. Well, give us one second here. I 3 don't -- 4 Q. I have two sheets. One that is 5 called pos-operative cardiothoracic operative 6 day orders. 7 A. Yes, ma'am. 8 Q. And then a second sheet of that. 9 A. Yes, ma'am. 10 Q. And then the next page I have, 11 which again may not be what you're looking 12 at. 13 A. Uh-huh. 14 Q. But I have several orders from 15 November 30th, 2005, and there is -- it ends 16 with a 12/1 -- 17 A. Uh-huh. 18 Q. -- telephone order? 19 MS. KINKOPF-ZAJAC: We have it. 20 Q. (By Ms. Perse) You have it? 21 A. Yes. 22 Q. Are there any entries, Dr. Bryant, 23 that you have entered into that record? 24 A. On the sheet that you are 25 referring to? 0281 1 Q. Yes. 2 A. Yes. 3 MS. PERSE: How about if -- so we 4 can make sure that we're speaking apples to 5 apples. We'll mark this as the next exhibit, 6 which would be the third exhibit for today's 7 deposition. 8 MS. KINKOPF-ZAJAC: Okay. 9 Q. (By Ms. Perse) And, again, just to 10 further identify it. It's the sheet entitle, 11 The Cleveland Clinic Foundation, Physician's 12 Orders, in the top left-hand corner. And the 13 bottom order is an order from 12/1 that 14 indicates it's a telephone order from Dr. 15 Bryant. 16 Doctor, I'm going to ask you to 17 read your entries into that record? 18 A. A-pace at 90 beats per minute. 19 Hespan, 500 milliliters times one. Neo, 100 20 mgs. IV times one. At the bottom of that 21 page, it says, 250 of Hespan times one. 22 Q. Do you know when those orders were 23 written? 24 A. I would say the dates that are 25 indicated next to the order. 0282 1 Q. There are timed? 2 A. No. They aren't timed. 3 Q. Did you write any note, correlating 4 to those orders? 5 A. I don't -- well, the only notes 6 that we have are from the morning of -- of 7 the -- of -- of December 1st. 8 Q. So can you tell me why you ordered 9 the atrial pacing at 90 beats per minute? 10 A. Well, it would appear that the 11 patient had some lower heart rate and because 12 of his lower blood pressure, we chose to 13 A-Pace him to increase his cardiac output and 14 get his blood pressure up. So we A-Paced 15 and also gave volume. 16 Q. The atrial pacing. When you 17 ordered it at 90 beats per minute. Who 18 actually does that adjustment to the atrial 19 pacemaker? 20 A. The nursing staff. 21 Q. Do you do anything at the bedside 22 with Michael -- or with a patient like 23 Michael Orra to initiate the atrial pacing? 24 A. No. Usually the nurses take care 25 of that. 0283 1 Q. So that is totally a nursing -- 2 their practice? 3 A. Usually. 4 Q. Do you know whether it was done by 5 the nurses or by yourself, personally, in 6 Michael Orra? 7 A. Well, the order doesn't indicate 8 it, but I would say that the nurses did it. 9 Q. I'm sorry. What was the final 10 part? 11 A. The -- the order doesn't indicate 12 who did it, but I would say that the nurses 13 did it. 14 Q. Do you know how long Michael Orra 15 was atrially paced? 16 A. I can refer to the record. 17 Q. Was he atrially paced when you 18 wrote your 12/1/05 note? 19 A. It would appear not. 20 Q. And is it correct that you didn't 21 write a note to say why he was -- why you 22 atrially paced him? 23 A. No. I didn't write a note 24 specifically to that affect. 25 Q. Did you order EKGs on Michael 0284 1 Orra, post-operatively? 2 A. No. He gets EKGs. I mean, 3 that's a routine, post-operative occurrence. 4 Q. Did you sign off on any of the 5 standing orders? 6 A. You mean the post-operative orders? 7 Q. The standing post-operative orders. 8 Yes. 9 A. I signed off on the orders that 10 you see. The post-operative car -- 11 cardiothoracic operative day orders, dated 12 November 30th. 13 Q. You signed off on those? 14 A. Yes. My signature is on those. 15 Q. On Page 2 of the standing orders. 16 There is a checklist of orders. Did you 17 complete that checklist? 18 A. Yes. 19 Q. Can we agree that -- that you put 20 the -- the check next to the stat 12 lead 21 EKG? 22 A. Yeah. Sure. We can agree to 23 that. 24 Q. And if you didn't want doctor -- 25 or Michael Orra to get an EKG, you would not 0285 1 have left a check mark, correct? 2 A. That is correct. 3 Q. Did you check the results of that 4 EKG? 5 A. Well, I don't remember specifically 6 seeing it, but I'm sure I probably looked at 7 it. 8 Q. And what -- what was the 9 indication for the EKG in Michael Orra? 10 A. It is part of our routine 11 post-operative orders. Everyone gets a chest 12 pray. Everyone gets a 12 lead EKG. Everyone 13 gets a potassium, hematocrit, and glucose with 14 ABG. Everyone is on the post-operative 15 incident protocol. Everyone -- 16 MS. KINKOPF-ZAJAC: Just answer her 17 question. Okay? 18 A. So it's part of the post-operative 19 routine. 20 Q. (By Ms. Perse) In Michael Orra, 21 what would you be looking for on that EKG? 22 MS. KINKOPF-ZAJAC: Objection. I 23 think he just said it's part of the routine. 24 Go ahead. 25 A. It's -- it's part of the 0286 1 post-operative routine. Standing orders. 2 Q. (By Ms. Perse) As far as the 3 standing order, what would you be looking for 4 on that EKG? 5 MS. KINKOPF-ZAJAC: Objection. 6 A. Well, the characteristics of the 7 EKG. Any significant changes from the 8 pre-operative EKG. 9 MS. KINKOPF-ZAJAC: Keep your voice 10 up. 11 Q. (By Ms. Perse) I am going ask -- 12 refer you to the EKG section -- 13 A. Okay. 14 Q. -- of your record. 15 MS. KINKOPF-ZAJAC: We don't have 16 those records. 17 MS. PERSE: You don't have those 18 records? 19 MS. KINKOPF-ZAJAC: No. He just 20 has what the records are that he was involved 21 in. 22 MS. PERSE: I'm sorry. What? 23 MS. KINKOPF-ZAJAC: He just has 24 the records that he was involved in. That's 25 all I have. 0287 1 Q. (By Ms. Perse) Can we agree, 2 Doctor, that if you ordered the stat EKG in 3 the post-operative period, it would have been 4 done between 7:00 p.m. and 7:00 a.m., 5 November 30th, 2005 to December 1st, 2005? 6 MS. KINKOPF-ZAJAC: Objection. 7 A. Ideally, yes. Does it always 8 happen that way? No. 9 Q. (By Ms. Perse) We agree if an EKG 10 was done during that post-operative period, it 11 was your responsibility as the resident 12 on-call to review that EKG? 13 MS. KINKOPF-ZAJAC: Objection. Go 14 ahead. 15 A. I would agree that any practitioner 16 in the ICU would have seen that EKG, in 17 addition to myself. 18 Q. (By Ms. Perse) But it would be 19 your responsibility, correct? 20 MS. KINKOPF-ZAJAC: Objection. 21 A. It would be part of my 22 responsibilities. Yes. 23 Q. (By Ms. Perse) And if there was an 24 abnormality on that EKG, it would be your 25 responsibility to report that to the attending 0288 1 surgeon? 2 MS. KINKOPF-ZAJAC: Objection. 3 A. Well, it would depend on what the 4 abnormality was. 5 Q. I'm sorry. What? 6 A. It would depend on what the 7 abnormality was. 8 MS. KINKOPF-ZAJAC: How we doing 9 time-wise? 10 MS. PERSE: Almost -- we're -- 11 we're getting there. 12 MS. KINKOPF-ZAJAC: We need to get 13 there. We -- we really need -- 14 MS. PERSE: Not -- not the 15 complete, but to get this put together here. 16 MS. KINKOPF-ZAJAC: We really need 17 to get there. I mean, this has been a long 18 day already and -- and it's time. 19 Q. (By Ms. Perse) Doctor, if an 20 abnormality agree -- appeared on an EKG in 21 the post-operative period when you were 22 on-call, would you agree that it would be 23 your responsibility to act on that abnormality 24 and report that to the attending physician> 25 MS. KINKOPF-ZAJAC: Objection. 0289 1 Asked and answered. Go ahead. 2 A. Well, I would say it would depend 3 on the abnormality and whether the abnormality 4 was present on the pre-operative EKG. If 5 there aren't any significant changes between 6 the post-operative EKG and the pre-operative 7 EKG, one would have to make that 8 interpretation and judgment at the time. 9 Q. (By Ms. Perse) If there were 10 changes that were significant from 11 pre-operative, the pre-operative EK dre -- G, 12 would you agree it would be your 13 responsibility to act on those changes? 14 A. Well, what do you -- 15 MS. KINKOPF-ZAJAC: Objection. Go 16 ahead. 17 A. What -- what do you mean by 18 significant? 19 Q. (By Ms. Perse) That was using your 20 answer to the previous question. You had 21 described it as significant changes. 22 A. I'm saying it would depend on the 23 abnormality. 24 Q. We can agree that you would have 25 no way of knowing the abnormality unless you 0290 1 reviewed that EKG. Correct? 2 A. That's correct. 3 Q. You there? 4 MS. KINKOPF-ZAJAC: He answered it. 5 A. I said that's correct. 6 Q. (By Ms. Perse) Okay. I'm sorry. 7 It didn't come through. I apologize. 8 Doctor, did you have any 9 conversations with the Orra family? 10 A. No, ma'am. 11 Q. I'm sorry. I didn't hear your 12 answer. 13 A. No, ma'am. 14 Q. Do you recall who the nurse was, 15 who was taking care of Dr. Orra the night 16 that you were on-call? 17 A. No, ma'am. 18 Q. Do you remember any conversations 19 with the nursing staff? 20 A. Not specifically. No. I do not. 21 Q. Well, when -- when you say not 22 specifically. Do you have any general 23 recollection of a conversation with nursing 24 staff? 25 A. No. 0291 1 Q. Do you have any criticisms of the 2 care that Michael Orra received while a 3 patient at the clinic? 4 A. No. 5 Q. Doctor, how about if -- if you 6 give me the luxury of a five or ten-minute 7 break. You've been very patient. 8 MS, KINKOPF-ZAJAC: We don't have 9 five or ten minutes, Jessica. I'm sorry. I 10 -- I -- I really am sorry, but we don't have 11 five or ten minutes. 12 MS. PERSE: Yeah. I am going to 13 go ahead and take a five-minute break. And 14 if you just want to wait for that time, I'll 15 be back in five. 16 THE VIDEOGRAPHER: Do you agree to 17 go off the record? 18 MS. KINKOPF-ZAJAC: Yes. Please 19 go off the record. 20 THE VIDEOGRAPHER: We are off the 21 record. It is seven minutes after 11:00 a.m. 22 (Recess taken at 11:07 a.m. until 23 11:10 a.m.) 24 THE VIDEOGRAPHER: We are on the 25 record. It is ten minutes after 11:00 a.m. 0292 1 MS. KINKOPF-ZAJAC: All set. 2 Q. (By Ms. Perse) Okay. Doctor, just 3 a couple of additional questions. The last 4 time we convened, we were discussing your 5 board status, and I'm curious, have you had 6 the opportunity to take any board testing 7 since last time we spoke? 8 A. What kind of board testing? 9 Q. Are you going to sit for the 10 thoracic boards? 11 A. In December. 12 Q. I'm sorry. What? 13 A. In December. 14 Q. In December? 15 A. Correct. 16 Q. I'm going to need you to speak up. 17 I know we're -- it's been a long morning. 18 A. Yes. In December. 19 Q. So in December of 2008, you will 20 be sitting for the thoracic boards? 21 A. Yes. 22 Q. Since we last met, -- 23 A. Uh-huh. 24 Q. -- have you reviewed any materials? 25 A. For this case? 0293 1 Q. Yes. 2 A. My previous deposition. 3 Q. So you had an opportunity to 4 review your transcript? 5 A. I did. 6 Q. I'm sorry. Doctor, did you answer 7 to -- 8 A. Yes. I said I did have a chance 9 to review it. Most of it. 10 Q. Anything else? 11 A. No. 12 Q. Doctor, short of asking my next 13 question before your answer, due to the 14 quality of the telephone communication. Have 15 I been fair to you during this deposition? 16 MS. KINKOPF-ZAJAC: Objection. 17 A. Sure. 18 Q. (By Ms. Perse) Have I given you an 19 opportunity to answer the questions? 20 A. Yes, ma'am. 21 Q. Doctor, I want to thank you for 22 your time and especially making yourself 23 available for this separate -- second meeting. 24 I appreciate that. 25 MS. PERSE: And with that, I'm 0294 1 going to close the deposition. 2 MS. KINKOPF-ZAJAC: Okay. 3 THE WITNESS: Thank you. 4 MS. KINKOPF-ZAJAC: Thank you. 5 You have the right to read over the 6 transcript, And I will send you a copy of 7 the second transcript. 8 THE WITNESS: Okay. 9 MS. KINKOPF-ZAJAC: We'll waive the 10 video. We'll go off the record. Thank you. 11 THE VIDEOGRAPHER: Off the record. 12 It is 11:13. 13 (Exhibits-C&D&E were marked.) 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0295 1 DESCRIPTION OF EXHIBITS 2 EXHIBIT DESCRIPTION 3 C (Operative notes) 4 D (Clinical Sheet) 5 E (Physician's Orders) 6 . 7 . 8 . 9 . 10 . 11 . 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0296 1 REPORTER'S CERTIFICATION 2 CONTINUED ORAL AND VIDEOTAPED DEPOSITION OF 3 ROOSEVELT BRYANT, III, M.D. 4 July 25, 2008 5 STATE OF TEXAS: 6 COUNTY OF HARRIS: 7 I, JUDY H. GALLO, Certified 8 Shorthand Reporter for the State of Texas, do 9 hereby certify that the foregoing transcript 10 is a true, correct and complete transcription, 11 to the best of my ability, of the proceedings 12 had at the time and place stated in the 13 caption hereto. 14 Given under my hand and seal of 15 office on this the _____ day of _____________ 16 2008. 17 . 18 _______________________________ 19 JUDY H. GALLO, Texas CSR 794 20 Expiration Date: 12-31-08 21 . 22 . 23 . 24 . 25 . 0297 1 CAPTION 2 The Deposition of Roosevelt Bryant, 3 III, M.D., taken in the matter, on the date, 4 and at the time and place set out on the 5 title page hereof. 6 It was requested that the deposition 7 be taken by the reporter and that same be 8 reduced to typewritten form. 9 It was agreed by and between counsel 10 and the parties that the Deponent will read 11 and sign the transcript of said deposition. 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0298 1 CERTIFICATE 2 STATE OF : 3 COUNTY/CITY OF : 4 Before me, this day, personally 5 appeared, Roosevelt Bryant, III, M.D., who, 6 being duly sworn, states that the foregoing 7 transcript of his/her Deposition, taken in 8 the matter, on the date, and at the time and 9 place set out on the title page hereof, 10 constitutes a true and accurate transcript of 11 said deposition. 12 13 Roosevelt Bryant, III, M.D. 14 . 15 SUBSCRIBED and SWORN to before me this 16 day of , 2008 in 17 the jurisdiction aforesaid. 18 19 My Commission Expires Notary Public 20 . 21 . 22 . 23 . 24 . 25 . 0299 1 DEPOSITION ERRATA SHEET 2 . 3 RE: SetDepo, Inc. 4 File No. 18541 5 Case Caption: Amne Orra vs. Cleveland 6 Clinic Foundation, et al. 7 Deponent: Roosevelt Bryant, III, M.D. 8 Deposition Date: July 25, 2008 9 . 10 To the Reporter: 11 I have read the entire transcript of my 12 Deposition taken in the captioned matter or 13 the same has been read to me. I request 14 that the following changes be entered upon 15 the record for the reasons indicated. I 16 have signed my name to the Errata Sheet and 17 the appropriate Certificate and authorize you 18 to attach both to the original transcript. 19 . 20 Page No. Line No. Change to: 21 22 Reason for change: 23 Page No. Line No. Change to: 24 25 Reason for change: 0300 1 Page No. Line No. Change to: 2 Reason for change: Page No. Line No. Change to: 3 Reason for change: 4 Page No. Line No. Change to: 5 Reason for change: Deposition of Roosevelt Bryant, III, M.D. 6 . Page No. Line No. Change to: 7 Reason for change: 8 Page No. Line No. Change to: 9 Reason for change: Page No. Line No. Change to: 10 11 Reason for change: 12 Page No. Line No. Change to: 13 14 Reason for change: 15 Page No. Line No. Change to: 16 17 Reason for change: 18 Page No. Line No. Change to: 19 20 Reason for change: 21 . 22 . 23 SIGNATURE:_______________________DATE:___________ 24 Roosevelt Bryant, III, M.D. 25