1 1 STATE OF OHIO ) 2 COUNTY OF CUYAHOGA ) 3 4 IN THE COURT OF COMMON PLEAS 5 CASE NO. 374280 6 JUDGE WILLIAM J. COYNE 7 8 G. DELORES SAVAGE, as legally * 9 appointed Guardian for WANDA * 10 WRIGHT, an incompetent, et al.,* 11 Plaintiffs, * 12 vs. * Deposition of: 13 COLUMBIA/HCA HEALTHCARE CORP., * SOLON EDWARD 14 et al., * DAVIS, III 15 Defendants. * 16 - - - - - - - - - - - - - - - - 17 18 Deposition of: 19 SOLON EDWARD DAVIS, III, M.D. 20 October 24, 2000 21 22 SCHULMAN, CICCARELLI & WIEGMANN 23 CERTIFIED SHORTHAND REPORTERS 24 EDISON TOMS RIVER ATLANTIC CITY 25 (732) - 494 - 9100 2 1 T R A N S C R I P T of the 2 stenographic notes of the proceedings in the 3 above-entitled matter as taken by and before 4 GAIL D. MILLARES, a Certified Shorthand 5 Reporter and Notary Public of the State of New 6 Jersey, held at Hackensack University Medical 7 Center, Hackensack, New Jersey, on Tuesday, 8 October 24, 2000, commencing at approximately 9 1:13 in the afternoon, pursuant to notice. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3 1 A P P E A R A N C E S: 2 3 LINTON & HIRSHMAN, ESQS. 4 Attorneys for the Plaintiffs 5 Hoyt Block, Suite 300 6 700 West St. Clair Avenue 7 Cleveland, Ohio 44113-1230 8 BY: TOBIAS H. HIRSHMAN, ESQ. 9 10 BUCKINGHAM, DOOLITTLE & BURROUGHS, LLP 11 Attorneys for the Defendants Columbia/St. 12 Luke Medical Center and Nurse Burton 13 4518 Fulton Drive, NW 14 Canton, Ohio 44735-5548 15 BY: MARK D. FRASURE, ESQ. 16 17 REMINGER & REMINGER, ESQS. 18 Attorneys for the Defendants, Dr. Liu, 19 Dr. Gyves and Nurse/Midwife Nuza 20 The 113th St. Clair Building 21 Cleveland, Ohio 44114 22 BY: ALAN B. PARKER, ESQ. 23 24 25 SCHULMAN, CICCARELLI & WIEGMANN 4 1 I N D E X 2 WITNESS DIRECT CROSS REDIRECT RECROSS 3 S. EDWARD 4 DAVIS, III 5 By: Mr. Parker 5 100 6 By: Mr. Frasure 64 7 8 9 10 11 12 13 14 E X H I B I T S 15 NUMBER DESCRIPTION PAGE 16 17 D-1 Curriculum vitae 5 18 19 D-2 Letter dated June 22, 2000 5 20 to Tobias J. Hirshman, Esq., 21 from S. Edward Davis, III 22 23 24 25 SCHULMAN, CICCARELLI & WIEGMANN 5 Davis - Direct - Parker 1 (Whereupon, Curriculum vitae 2 received and marked Exhibit D-1 for 3 Identification; and 4 Letter dated June 22, 2000 to 5 Tobias J. Hirshman, Esq., from S. Edward Davis, 6 III, received and marked Exhibit D-2 for 7 Identification.) 8 9 S O L O N E D W A R D D A V I S, III, 10 practicing at Hackensack University 11 Medical Center, 30 Prospect Avenue, 12 Hackensack, New Jersey is duly sworn by 13 a Notary Public of the State of New 14 Jersey and testifies under oath as 15 follows: 16 17 DIRECT EXAMINATION BY MR. PARKER: 18 19 Q Will you state your full name for 20 the record, please. 21 A First name Solon, S-o-l-o-n. Edward is 22 my middle name and then Davis, D-a-v-i-s, and 23 I'm the third. 24 Q And your professional address? 25 A It would be the Hackensack University SCHULMAN, CICCARELLI & WIEGMANN 6 Davis - Direct - Parker 1 Medical Center which is at 30 Prospect Avenue 2 in Hackensack, New Jersey. 3 Q Dr. Davis, my name is Alan 4 Parker. I'm an attorney. I'm here 5 representing Dr. Liu and Dr. Gyves and 6 Nurse/Midwife Nuza. 7 Have you had your deposition 8 taken before? 9 A Yes. 10 Q Then you probably understand that 11 this is my opportunity to ask you questions. 12 It is not my intent to ask you confusing 13 questions but I'll probably do it on occasion 14 anyway. If my questions don't make sense or 15 are confusing, let me know and I will do my 16 best to rephrase them. 17 Fair enough? 18 A Yes. 19 Q What is your profession? 20 A I am an obstetrician/gynecologist, 21 specifically a maternal-fetal medicine 22 specialist or subspecialist. 23 Q Let me show you what has been 24 marked as Defendant's 1. Is that a copy of 25 your curriculum vitae? SCHULMAN, CICCARELLI & WIEGMANN 7 Davis - Direct - Parker 1 A Yes. 2 Q Is it current? 3 A Yes. 4 Q It should save me a lot of 5 questions then. 6 Are you board certified? 7 A Yes. 8 Q In what fields? 9 A Obstetrics, gynecology and I have a 10 certificate of special competence in 11 maternal-fetal medicine. I was recertified in 12 June of '95 in both OB/GYN and MFM. 13 Q Are the offices here at 14 Hackensack Medical Center the only location you 15 practice out of? 16 A Yes. 17 Q Can you describe for me, please, 18 the nature of your practice? 19 A Essentially I take care of high risk 20 obstetrical patients and my involvement goes 21 all the way from consultations, ultrasound 22 exams, comanagement to actual full range of 23 care for such patients. 24 Q Does your practice also encompass 25 general obstetrics or is it pretty much all SCHULMAN, CICCARELLI & WIEGMANN 8 Davis - Direct - Parker 1 high risk obstetrics? 2 A It's pretty much all high risk 3 obstetrics. I do have some patients that are 4 not high risk, but to be one of my patients, 5 they have to have some feature that kind of 6 introduced them. I'm not in competition with 7 our generalist here. 8 They may, for example, have been 9 high risk when I took care of them in a 10 previous pregnancy and they come back for me to 11 take care of them for this one. 12 I would take care of any medical 13 personnel. I don't think I currently have any 14 that are candidates for that, and I have some 15 that have had some feature in the past which 16 has increased their risk for care. 17 Q Typically, are you called in to 18 examine and treat patients during their 19 prenatal course or is it typically that you're 20 involved just during the labor and delivery 21 stages or both? 22 How would you describe it? 23 A It would be both. The kind of 24 description that I've given for what 25 perinatologists do is they are frequently SCHULMAN, CICCARELLI & WIEGMANN 9 Davis - Direct - Parker 1 called in when things are a disaster and asked 2 to fix it. I mean, that's kind of the origin 3 of what we do, but we do things all the way 4 from patients that are frankly ill at the time 5 that we meet them and with a pregnancy that is 6 crashing to those that, in fact, just have 7 factors which make them more likely to get sick 8 in the course of the pregnancy but are 9 perfectly well. 10 Q In this case, Ms. Wanda Wright, 11 was she a high risk pregnancy before she 12 presented for labor and delivery? 13 A Actually, she was. 14 Q Why is that? 15 A Well, she was over the age of 42. There 16 are some people that draw the line at 35 to say 17 that makes her advanced maternal age. I 18 personally think you have to be approaching the 19 age of 40, but anyone who is 38, 39, 40 or 20 above as far as I'm concerned really qualifies 21 as a high risk patient. 22 Q Did the standard of care require 23 that this patient be sent to a high risk 24 specialist solely because of her age? 25 A No. SCHULMAN, CICCARELLI & WIEGMANN 10 Davis - Direct - Parker 1 Q I just had your CV printed before 2 we started the deposition so I have not really 3 reviewed it. 4 Have you published on any 5 subjects that are particularly relevant to the 6 issues in this case? 7 A Not that are key to this case. 8 Q Okay. 9 And I haven't even reviewed it to 10 see whether you do presentations or lectures. 11 Do you, sir? 12 A Yes. 13 Q And have you given presentations 14 or lectures on issues that are particularly 15 pertinent to this case? 16 A Actually, yes. 17 Q Can you tell me about that, 18 please? 19 A Well, from time to time over the years I 20 certainly have talked about issues of platelet 21 consumption, hypercoagulability and the 22 management of hypertension in pregnancies. 23 These are kinds of bread and butter type issues 24 for maternal-fetal specialists. 25 Q You told me at the outset of the SCHULMAN, CICCARELLI & WIEGMANN 11 Davis - Direct - Parker 1 deposition that you have been deposed before. 2 A Yes. 3 Q Have you served as an expert 4 witness in medical-negligence type cases 5 before? 6 A Yes. 7 Q On approximately how many 8 occasions? 9 A I don't know. It would depend on how 10 you define expert. If you talk about the 11 review of cases in one manner or another, it 12 would certainly be hundreds. If you talk about 13 going to the point of testimony, it would still 14 probably be in excess of a hundred over what 15 are getting to be a considerable number of 16 years now. 17 Q When did you start making 18 yourself available as an expert witness? 19 A Back in the early '70s. 20 Q And have you had occasion to 21 testify at trial? 22 A Yes. 23 Q On approximately how many 24 occasions? 25 A That would still be, you know--if you SCHULMAN, CICCARELLI & WIEGMANN 12 Davis - Direct - Parker 1 were to tell me it would have been a hundred 2 times, I certainly wouldn't argue with it. I 3 don't have a formal answer for that. 4 Q Have you testified in any federal 5 courts in the last three or four years? 6 A Yes. 7 Q In testifying in federal courts, 8 have you ever had to prepare a list of your 9 deposition and trial testimony? 10 A In theory I have, but it was never 11 challenged. 12 Q Was it ever--but was it ever 13 printed or created? 14 A No. 15 Q So you're not aware of any 16 currently existing list of cases-- 17 A No. 18 Q --in which you testified? 19 A No. 20 Q Can you give me an estimate of 21 the percentage of time that you testify in 22 favor of-- 23 (Whereupon, a discussion is held 24 off the record.) 25 Q Can you give me an estimate of SCHULMAN, CICCARELLI & WIEGMANN 13 Davis - Direct - Parker 1 the number of times that you have--the 2 percentage of times that you have testified on 3 behalf of patients versus that where you have 4 testified on behalf of health care providers? 5 A Plaintiffs of one kind or another would 6 probably be--I think 85 percent is probably 7 realistic. 8 Q When were you first contacted 9 with regard to this case? 10 A I frankly don't remember. 11 Q Do you know whether it was in the 12 calendar year 2000 or was it in the calendar-- 13 A I don't honestly remember. 14 Q Have you ever worked with Mr. 15 Hirshman before? 16 A Not to my knowledge. 17 Q Have you ever worked for his law 18 firm before? 19 A Not my knowledge. 20 Q Do you have knowledge as to how 21 Mr. Hirshman came to know of you or contact 22 you? 23 A I don't honestly know, but I would 24 assume it was because of other attorneys in the 25 Cleveland area. SCHULMAN, CICCARELLI & WIEGMANN 14 Davis - Direct - Parker 1 Q Have you testified in the 2 Cleveland area before? 3 A Yes. 4 Q On approximately how many 5 occasions? 6 A I would say maybe five times. That 7 would be a guess. 8 Q Okay. 9 Do you remember the names of any 10 of the attorneys who have used you in 11 Cleveland? 12 A Not off of the top of my head. You 13 know, we can kind of fish them up but that's 14 what we would have to do. 15 Q Are you listed with any services 16 that provide to attorneys medical-legal 17 reviews? 18 A I've been told that I'm listed with 19 some, but it was always with someone that I 20 didn't know anything about. 21 The answer is, do I have an 22 ongoing relationship of which I'm aware with 23 any organization, the answer is I'm not aware 24 of any. 25 Q Okay. SCHULMAN, CICCARELLI & WIEGMANN 15 Davis - Direct - Parker 1 Can you-- 2 A I certainly work through none. 3 Q I have a report which I took the 4 liberty of marking as Exhibit D-2-- 5 A Yes. 6 Q --dated June 22, 2000. 7 A Yes. 8 Q Is that a report that you 9 authored? 10 A Yes. 11 Q Have you authored any other 12 reports in this case? 13 A Not to my knowledge. 14 Q Were any drafts of this report 15 circulated? 16 A The answer is I'm not sure. I think I 17 may have ended up sending one and then, you 18 know, agreeing on this one. It would have 19 been, you know, spelling changes and maybe a 20 phrase here or there. 21 Q Do you recall any changes that 22 were made? 23 A I don't remember what they would have 24 been. 25 Q Would you have a copy or do you SCHULMAN, CICCARELLI & WIEGMANN 16 Davis - Direct - Parker 1 have a copy of any draft? 2 A No. 3 Q All right. 4 Can you tell me, please, what you 5 reviewed prior to authoring your report of June 6 22nd? 7 A I reviewed particularly the medical 8 record prior to the actual--through I guess the 9 operation. That was the chart particularly and 10 any depositions that I had regarding the people 11 that were there. I think probably of those 12 people, certainly Dr. Liu, Dr. Gyves, Nuza, I 13 think Burton. I'm not--there was less emphasis 14 on that, but those would have been the people 15 of which I'm aware. 16 Q Other than medical records and 17 depositions, did you review any other materials 18 in preparation for rendering a report? 19 A Nothing comes to mind. I'll be glad to 20 respond to any specific questions. 21 Q Have you reviewed any materials 22 in preparation for this case since authoring 23 the report? 24 A Well, I've seen the reports of your 25 experts. I think I pulled out and looked at a SCHULMAN, CICCARELLI & WIEGMANN 17 Davis - Direct - Parker 1 maternal-fetal text a few minutes ago and I 2 called a friend here who is a trauma surgeon. 3 Q What maternal-fetal text did you 4 refer to a few minutes ago? 5 A The Creasy & Resnick. 6 MR. FRASURE: How do you spell 7 that, Doctor? 8 THE WITNESS: It's standard 9 text. It's Maternal-Fetal Medicine by 10 C-r-e-a-s-y, and Resnick is R-e-s-n-i-c-k. 11 Q What edition do you have there? 12 A Fourth. 13 Q Have you reviewed any other 14 medical texts or literature in preparation for 15 rendering opinions in this case? 16 A Nothing comes to mind. 17 Q Okay. 18 A I do, of course, ongoing reading for 19 related conditions but that's not specifically 20 with regard to this. It just happens to be 21 something that I keep up with. 22 Q How long have you been practicing 23 in the field of high risk obstetrics? 24 A 1969, I guess. 25 Q As I understand it, and I guess SCHULMAN, CICCARELLI & WIEGMANN 18 Davis - Direct - Parker 1 let me ask you if you agree, this patient 2 manifested HELLP Syndrom-- 3 A Yes. 4 Q --at the time of her labor and 5 delivery. Is that true? 6 A Yes. 7 Q In the course of your career, how 8 often have you seen HELLP Syndrom in patients 9 you've treated? 10 A That's hard to be accurate. I mean, 11 it's not uncommon that some degree of platelet 12 consumption of the spectrum of disease ranging 13 from fatty liver pregnancy, hemolytic-uremic 14 syndrome, antiphospholipid syndrome, they can 15 kind of fade one into the other but I see that 16 with some frequency. 17 Q Have you yourself ever rendered a 18 diagnosis of HELLP Syndrome in a patient? 19 A Oh, surely. 20 Q On how many occasions as a 21 reasonable estimate? 22 A I don't know. As I say, it's not rare. 23 To give you an accurate answer, I don't know. 24 Q So it's not a rare condition? 25 A You mean conditions associated with SCHULMAN, CICCARELLI & WIEGMANN 19 Davis - Direct - Parker 1 hypertension involving platelet consumption? 2 Q I'm really asking about HELLP 3 Syndrom. 4 MR. HIRSHMAN: In his practice 5 you're talking about? 6 MR. PARKER: Yes. 7 A The answer is you don't see it every day 8 but you will see patients that manifest some 9 part of it certainly several times a year 10 without any question. 11 Q Within your practice, do you have 12 a working definition for what you consider to 13 be HELLP Syndrom? 14 A Not separate from, you know, what is 15 generally defined. 16 Q Can you give me a general 17 definition that you would recognize for HELLP 18 Syndrom? 19 A Well, it is one of the platelet 20 consumption conditions generally associated 21 with hypertension manifested by elevated liver 22 enzymes and thrombocytopenia. Microangiopatic 23 is the technical phrase for the classification 24 of condition that it is. 25 Q Do you consider HELLP Syndrome to SCHULMAN, CICCARELLI & WIEGMANN 20 Davis - Direct - Parker 1 be a subspecies of pregnancy-induced 2 hypertension or is it something separate or do 3 you not know? Can you educate me on that? 4 A No. I think it's considered to be part 5 of the spectrum related to preeclampsia. 6 Q Is preeclampsia synonymous with 7 induced hypertension or is that a-- 8 A No. They are all variants of kind of 9 the same thing. 10 Q How many-- 11 (Whereupon, a discussion is held 12 off the record.) 13 Q As I ask you these questions, 14 we're sitting in your office in what appears to 15 be a pretty good-sized medical center? 16 A Yes. 17 Q Can you give me an idea of the 18 number of patients that you examine and treat 19 on an annual basis? 20 A I would have a hard time. The ones that 21 I just take, I do maybe 50 or 60 deliveries a 22 year. I obviously interact with a lot more 23 patients than that and it depends on what 24 you're talking about in terms of interaction. 25 I obviously have a fair number of patients SCHULMAN, CICCARELLI & WIEGMANN 21 Davis - Direct - Parker 1 where I'm involved in the decision-making 2 process but it's considerably larger. 3 Q Sure, where you're participating 4 essentially with telephone consultations? 5 A Or in the hall or decisions written on 6 the chart. 7 Q And when you say considerably 8 larger, we would be dealing with thousands of 9 deliveries a year or what? 10 A Oh, no. No. It's probably, you know, 11 maybe three hundred a year. 12 Q Okay. 13 I am going to ask you a few 14 questions about your personal exposure to HELLP 15 Syndrome. I began that process. 16 Have you done any research 17 directed towards the issue of HELLP Syndrome? 18 A No. 19 Q Have you authored any 20 publications or contributed to the medical 21 literature on that subject? 22 A No. 23 Q Are you in a position to advise 24 me as to what you consider to be the most 25 reliable literature on the subject of HELLP SCHULMAN, CICCARELLI & WIEGMANN 22 Davis - Direct - Parker 1 Syndrome? 2 A Well, you're asking the question, as I 3 understand it, is there a single source that 4 you could go to or author that you would pick 5 as being an unequivocal source of wisdom. The 6 answer is no. There are multiple contributors 7 to it. 8 Q Who would you consider to be the 9 most authoritative? 10 A We don't use authoritative in medical 11 senses. 12 Q Who would be most helpful in your 13 opinion in the practice that you engage in? 14 A I don't know that I could think of a 15 single person that I would consider to be 16 distinctly a better source of insight than 17 anyone else. 18 Q Okay. 19 What causes HELLP Syndrome? 20 A That's a good question. 21 Q Is there a good answer or a known 22 answer? 23 A There isn't. 24 Q Are there risk factors for HELLP 25 Syndrome? SCHULMAN, CICCARELLI & WIEGMANN 23 Davis - Direct - Parker 1 A There are some characteristics, but the 2 answer is generally not I think in terms of 3 things that just make it obvious that this is a 4 patient that is going to develop HELLP Syndrome 5 versus some other form of toxemia. In fact, 6 usually the repetition for patients that have 7 had it will simply--if they're going to repeat, 8 are not probably going to repeat with the 9 syndrome sufficient that looks exactly like it 10 did last time. That's quite rare. 11 The highest repetition rate that 12 I'm aware of came out of the University of 13 Mississippi in which they talked I think in the 14 fifteen percent or more, but, once more, those 15 were not kind of fulminant type of cases. They 16 were just cases that had some of the aspects of 17 it. 18 Q Before Ms. Wright presented for 19 labor and delivery, did she exhibit anything 20 that was a red flag that HELLP Syndrome was 21 going to develop? 22 A You mean as she appeared at labor and 23 delivery or before? 24 Q Before she appeared at labor and 25 delivery. SCHULMAN, CICCARELLI & WIEGMANN 24 Davis - Direct - Parker 1 A Before they knew she was hypertensive? 2 Q Correct. 3 A No. 4 Q All right. 5 A Not to my knowledge. 6 Q What is the treatment for HELLP 7 Syndrome? 8 A Well, I think everyone would agree that 9 the treatment in general is delivery. 10 Q In general, can it be said that 11 delivery should be by cesarean section or 12 vaginal or is that case specific? 13 A I'd say it is case specific. 14 Q When do the symptoms of HELLP 15 Syndrome typically develop, in other words, the 16 hematology status, the thrombocytopenia, the 17 liver dysfunction? When is the onset of that? 18 MR. FRASURE: Within the 19 pregnancy? 20 MR. PARKER: Yes, within the 21 pregnancy. 22 A I've seen it at kind of every stage. 23 Q Is it fair to say it's something 24 that typically has its onset hours before 25 delivery or are we talking weeks before SCHULMAN, CICCARELLI & WIEGMANN 25 Davis - Direct - Parker 1 delivery or months before delivery or is it 2 highly variable? 3 A While it can develop and may be seen a 4 little time before, that's atypical. Most of 5 the time, it's in the immediate period before 6 delivery. 7 MR. FRASURE: Intermediate? I'm 8 sorry. 9 MR. HIRSHMAN: Immediate. 10 A Immediate. 11 Q I believe you told me earlier 12 that the generally-accepted treatment is 13 delivery. When does hematology status and the 14 liver status return to normal after delivery 15 typically? 16 A It's often several days. 17 Q Okay. 18 A Some cases often apparently worsen in 19 terms of--particularly in terms of lab values 20 after the delivery. The process is ongoing. 21 Q Are you familiar with any 22 literature or commonly accepted figures 23 regarding the prevalence of HELLP Syndrome? 24 A That's highly variable once more. If 25 you go back to the older literature, SCHULMAN, CICCARELLI & WIEGMANN 26 Davis - Direct - Parker 1 particularly in the south, there was not great 2 acceptance of the fact that toxemia or 3 preeclampsia was particularly associated with 4 platelet consumption. 5 One of the kind of major figures 6 in this was a fellow by the name of Jack 7 Pritchard at Parkland Hospital. For many 8 years, he thought this was particularly 9 inconsequential. 10 It appears in the south that 11 platelet conditions were often not particularly 12 seen whereas frequently in the north there were 13 more complaints that you end with platelet 14 consumption associated with toxemia of 15 pregnancy. What it is that's like this to my 16 knowledge has not been completely resolved. 17 As I say, elements of it as we 18 usually see it are not full blown. They will 19 be that we see a movement down but not critical 20 of platelet counts and some moderate elevation 21 in terms of liver and particularly elevations 22 of LDH which is probably associated with the 23 hemolytic component rather than mostly the 24 liver but they will not be such that the 25 patient is so grossly sick that that's SCHULMAN, CICCARELLI & WIEGMANN 27 Davis - Direct - Parker 1 completely controlling urgency in terms of 2 delivery other than you would be doing for the 3 toxemia itself. 4 Q I think my question or I intended 5 my question to be what is the prevalence of 6 this syndrome. I guess you're telling me it's 7 a complicated picture that you don't have a 8 clear answer on? 9 A It's a complicated picture depending on 10 where you want to say when are you willing to 11 call this HELLP, you see, because it's a 12 spectrum that fades from that picture in a 13 continuous fashion into the patients that get 14 really sick enough that you have to do things 15 other than deliver them. 16 Q Okay. 17 Have you seen published 18 prevalence statistics on HELLP Syndrome? 19 A I certainly have seen them. I certainly 20 have not taken them to heart. 21 Q Okay. 22 Obviously a major or the major 23 reason you're involved in the case is because 24 you have opinions regarding standard of care-- 25 A Yes. SCHULMAN, CICCARELLI & WIEGMANN 28 Davis - Direct - Parker 1 Q --with some of the health care 2 providers? 3 A Yes. 4 Q I want to ask you questions about 5 standard of care of my clients. 6 First of all, you authored a 7 report on June 22, 2000. Do you have any 8 additional deviations of standard of care that 9 were not set forth in your report? 10 A Regarding your clients or whatever? 11 Q Right. 12 A No. I think they're pretty much 13 summarized. 14 Q I did not see Dr. Gyves addressed 15 in your report. Do you have an opinion whether 16 he deviated from the standard of care? 17 A I do. 18 Q What is that opinion? 19 A Unless there is something of which I am 20 not aware which relates to the issue of 21 corporate involvement which would be the 22 decision to allow certain patients to be there 23 or the shape of the educational thing relating 24 to the hospital, I am not aware of his being 25 involved in any deviation. SCHULMAN, CICCARELLI & WIEGMANN 29 Davis - Direct - Parker 1 Q In other words, you don't see any 2 aspect in which his medical judgment was-- 3 A No. 4 Q --was wrong? 5 Dr. Liu, can you please tell me 6 how his conduct fell below the standard of 7 care? 8 A Well, I think it starts out by failure 9 to understand the seriousness of the patient's 10 condition, failure to respond in terms of being 11 personally involved in her care, and I think 12 under the set of circumstances seeing his 13 deposition, we would have to say that the 14 failure to see about transferring this patient 15 to someone who clearly understood more about 16 what the required care would be would certainly 17 be below the standard. 18 Q Any other aspects in which Dr. 19 Liu fell below the standard of care? 20 A Well, let me take a look. I'm not aware 21 of--other than you might say, well, the failure 22 to do this and the failure to do that, I mean, 23 those are I think involved in all the global 24 issues. 25 Obviously I think she should have SCHULMAN, CICCARELLI & WIEGMANN 30 Davis - Direct - Parker 1 been treated with antihypertensives 2 aggressively early. She should have had 3 aggressive early treatment, but that's all 4 related to his failure to understand how sick 5 the patient was and to address in an 6 appropriate fashion providing care for this 7 particular patient. 8 Q As I recall your report, you also 9 raised the issue about administration of 10 magnesium sulfate? 11 A Yes. 12 Q Do you have an opinion whether he 13 fell below the standard of care in the manner 14 in which that was ordered and administered? 15 A Well, I thought we indicated that 16 anybody who has a question about whether or not 17 this is a patient in urgent need of therapy--I 18 mean, hearing that she was in, had these 19 findings, should have resulted in his being 20 there and ordering them to set up to treat her 21 aggressively both with regard to the use of the 22 magnesium and with regard to the use of 23 antihypertensive medicines. That should have 24 been early and aggressive. 25 Q Okay. SCHULMAN, CICCARELLI & WIEGMANN 31 Davis - Direct - Parker 1 Were there any other medications 2 that should have been ordered that were not? 3 A You mean immediately or what? 4 Q During the time frame of the 5 patient's presenting to the time frame of the 6 discovery of the liver bleed. 7 A Well, as I've indicated, the main--he 8 should have been physically with this patient. 9 I mean, there was no one who could take his 10 place. As I've indicated, he should have 11 understood that his level of understanding of 12 this disease was not one which enabled him to 13 be her physician. 14 Q And I hear that. I'm simply 15 asking questions. I want to make sure by the 16 time I walk out of here that I have a 17 comprehensive understanding-- 18 A Yes. 19 Q --of your critiques. 20 A Yes. 21 Q And that's the only reason I'm 22 sort of picking at this in a little more 23 detail. 24 A Right. 25 Q Are you critical of any specific SCHULMAN, CICCARELLI & WIEGMANN 32 Davis - Direct - Parker 1 failures to perform or order specific 2 diagnostic tests? 3 A Well, you could say that when she began 4 to complain, which he did not know about and 5 partly didn't know about because he was not 6 there, when she was complaining of shoulder 7 cramps, obviously at that point one should be 8 thinking of doing ultrasound of the liver. 9 Q Anything else? 10 A That's pretty much it, I think. 11 Q All right. 12 A And obviously he was not there to 13 respond to the bradycardia. You just go 14 through and the things that are wrong obviously 15 were deviations because he wasn't there to 16 respond to them. He wasn't there to respond to 17 getting--to alerting surgeons and all of these 18 things which would have been standard of care 19 in a tertiary center. 20 Q I'm going to go back to each of 21 those three or four categories and try to flesh 22 that out a little more. You testified he fell 23 below the standard of care in failing to 24 understand the seriousness of the condition. 25 A Yes. SCHULMAN, CICCARELLI & WIEGMANN 33 Davis - Direct - Parker 1 Q Explain to me what you see in 2 this case that manifests that falling below the 3 standard of care in that regard. 4 A This is an advanced maternal age patient 5 with sudden onset of proteinuric hypertension. 6 Patients that fall into that category are at 7 special risk of dying. They may not die from 8 this complication but they are certainly at 9 risk to end up dying because they bleed into 10 their brains. 11 The point of it is that this is a 12 patient that under no circumstances should be 13 treated as a garden variety case of toxemia who 14 is highly unlikely to get into serious 15 trouble. 16 Q Okay. 17 A There is nothing that I see that shows 18 any evidence of comprehension of the 19 extraordinary risk that this patient 20 presented. Once you know that she's spilling 21 protein and she has not just hypertension but 22 she has-- 23 (Whereupon, a discussion is held 24 off the record.) 25 Q You were saying you saw no SCHULMAN, CICCARELLI & WIEGMANN 34 Davis - Direct - Parker 1 evidence of comprehension of the patient in 2 this higher risk. 3 A You were asking what was it that 4 immediately told me about that. 5 Q Not immediately but what is it 6 that supports--you see as support for your 7 opinion that he failed to understand the 8 seriousness of the condition. You started-- 9 A Well, there was no real response to the 10 fact that she had a blood pressure of 207/100 11 and was I believe spilling either three or four 12 plus protein. 13 I mean, if this doesn't scare the 14 daylights out of you, you just don't know what 15 you're dealing with in a 42-year-old patient. 16 Q Okay. 17 So does that pretty much cover 18 that category? It's going to lead us into the 19 next one I think. 20 A Okay. 21 Q The failure to personally respond 22 to the condition. 23 A Yes. 24 Q Had Dr. Liu come to the 25 hospital--first of all, do you have an opinion SCHULMAN, CICCARELLI & WIEGMANN 35 Davis - Direct - Parker 1 as to when he should have been there to comply 2 with the standard of care? 3 A He should have been there or on his way 4 before the telephone reached the cradle. 5 Q What is your understanding as to 6 when he was notified of the patient's 7 admission, blood pressure and proteinuria 8 status? 9 A It says in my report, initial contact 10 between the nurse-midwife who evaluated the 11 patient and the responsible attending physician 12 was one-thirty. 13 Q It's your opinion in order to 14 comply with the standard of care he needed to 15 depart for the hospital at one-thirty assuming 16 that is the correct time? 17 A Right. He should have told them to 18 prepare to treat this patient, you know. 19 Apparently there was some problems in terms of 20 starting the mag sulfate but it should have 21 been started immediately and they should have 22 been prepared to drop her blood pressure 23 essentially immediately as well. 24 Q What do you mean when you say he 25 should have been prepared to give instructions SCHULMAN, CICCARELLI & WIEGMANN 36 Davis - Direct - Parker 1 on how to treat this patient? What 2 specifically are you referring to he should 3 have been doing? 4 A As I indicated, the two things that are 5 most important in terms of this are really 6 bringing the blood pressure down and beginning 7 to give her mag sulfate. 8 Q What is the purpose of 9 administering mag sulfate? 10 A Prophylaxis against convulsions is kind 11 of the standard answer. 12 Q Is magnesium sulfate approved for 13 use to prevent convulsions? 14 A I don't have any idea. It's the 15 standard of care, though, in this country. 16 Q Okay. 17 A It certainly isn't for anything other 18 than toxemia, but it is in this country the 19 standard treatment. Now, there are Europeans 20 that would say you're better off using 21 anticonvulsants. In point of fact, when they 22 have been run head to head, the efficacy of mag 23 sulfate has generally been considered to be 24 superior. 25 Q Did this patient have SCHULMAN, CICCARELLI & WIEGMANN 37 Davis - Direct - Parker 1 convulsions? 2 A No. 3 Q Does the magnesium sulfate play 4 any other role in the treatment of this kind of 5 patient other than as prophylaxis to 6 convulsions? 7 A There has been a question as to whether 8 or not it changes the course of the disease and 9 that I would consider still up for grabs, but 10 certainly it has been raised by people that are 11 considered to be expert in this. 12 Q Did the delay in administering 13 magnesium sulfate to this patient change the 14 outcome in any respect? 15 A In this case, it didn't. 16 MR. FRASURE: I'm sorry? Did 17 not? 18 THE WITNESS: Did not. 19 Q You also indicated that the other 20 medication--the other I guess--the medication 21 approach would be to get the blood pressure 22 under control? 23 A Right. 24 Q I think that you indicated in 25 your report, and I can never say it right-- SCHULMAN, CICCARELLI & WIEGMANN 38 Davis - Direct - Parker 1 A Labetelol. Black patients may not 2 respond particularly well to it but it is kind 3 of the standard thing that's used. Apresoline 4 would be another medication that would be very 5 standard and certainly appropriate to use. If 6 you can't do it any other way, Sodium 7 Nitroprusside is certainly another thing that's 8 normally administered by intensive care or 9 critical care personnel or anesthesiologists 10 but, you know, should certainly be available in 11 any hospital that ought to be treating this 12 kind of patient. 13 Q What do you think is standard of 14 care for this patient as far as-- 15 A Standard of care is to bring her blood 16 pressure down by whatever means is appropriate. 17 Q Okay. 18 A And efficacious. 19 Q I think I heard you mention 20 earlier in your deposition one of the major 21 dangers of hypertension in pregnancy is the 22 risk of a bleed into the brain. Is that true? 23 A Yes. 24 Q Is that indeed the primary reason 25 for giving blood pressure medication in this SCHULMAN, CICCARELLI & WIEGMANN 39 Davis - Direct - Parker 1 scenario, to prevent that from occurring? 2 A It certainly would be the primary. 3 Q In this case, is there any 4 evidence of a bleed into the brain? 5 A No, but there is probably evidence of 6 hypertensive encephalopathy. 7 Q Are you telling me that you have 8 an opinion that this patient suffered 9 specifically from hypertensive encephalopathy? 10 A What I'm saying, one of the critical 11 factors that appears in this patient is 12 concerned over just how high--how long her 13 brain was subjected to clearly blood pressures 14 which are in the range to raise the question of 15 hypertensive encephalopathy. 16 Q Is it fair to state that there 17 would also be a concern in this case that the 18 patient's encephalopathy may be due to 19 hypotension or low platelets or, you know-- 20 A I'm not aware of the low platelets. 21 Q Or a decrease in blood supply? 22 A I'm not aware of the low platelets. The 23 hypertension especially followed by hypotension 24 where you have got the combination of 25 compromise of the cerebrovasculature, the SCHULMAN, CICCARELLI & WIEGMANN 40 Davis - Direct - Parker 1 cerebral edema followed by a period of 2 hypotension, that's a particularly concerning 3 combination, yes. 4 Q Whether or not that combination 5 of hypertension and/or hypotension caused Ms. 6 Wright's encephalopathy and coma, is that a 7 topic that you anticipate giving opinions on or 8 is that a topic in which you would defer to 9 neurologists and other experts on? 10 A My only comments would be the ones that 11 we have just covered. If you're asking do I 12 consider myself to be comparable in terms of 13 expertise to a neurologist, the answer is no. 14 Am I--is it an area which is an MFM person, I 15 would express that we would specifically be 16 concerned about the possibility of in such a 17 patient, the answer is we would specifically be 18 concerned about that possibility in a patient 19 like this. 20 Q Have you formulated an opinion as 21 to whether Ms. Wright's encephalopathy is 22 causally related to her hypertension? 23 A I have, yes. 24 Q Okay. 25 Are there any diagnostic tests or SCHULMAN, CICCARELLI & WIEGMANN 41 Davis - Direct - Parker 1 findings that-- 2 MR. HIRSHMAN: You don't want his 3 opinion? 4 Q --that tell us that her 5 encephalopathy and coma was caused by 6 hypertension? 7 A As opposed to anything else 8 contributing? 9 Q Correct. 10 A The answer is I'm not aware that you can 11 separate out all of these things. All you can 12 be aware of is what certain physiologic and 13 pathophysiologic features would be in terms of 14 changing the risk of these things occurring. 15 Those would be commonly accepted. They're not 16 kind of private opinions that only I kind of 17 share. 18 I'm trying to look up there. 19 There is, you know, certainly almost half a 20 shelf of books up there simply related to the 21 issue of hypertension. So this is not 22 something, you know, that I developed a 23 fleeting interest in only five minutes ago. I 24 mean, this is one of the things that I've been 25 concerned about a very long period of time as SCHULMAN, CICCARELLI & WIEGMANN 42 Davis - Direct - Parker 1 would theoretically any competent maternal 2 medicine person. 3 Q What is it about Ms. Wright's 4 condition that leads you to believe that 5 hypertension specifically played a role in her 6 encephalopathy? 7 A Well, the fact that she went on for 8 several hours with these kind of completely 9 uncontrolled blood pressures. 10 Q Anything else? 11 A That's--and the fact she was pregnant. 12 That changes the likelihood of moving things to 13 develop cerebral edema. 14 Q We've been discussing for the 15 last minutes your opinion that Dr. Liu should 16 have come in immediately upon being informed of 17 the patient's blood pressure and proteinuria. 18 Then we were discussing what he should have 19 done in terms of medications. Now I want to 20 ask you what else should he have done had he 21 been there in person. 22 A Well, understanding his level of 23 comprehension of this condition, he should have 24 transferred the patient out. 25 Q And do you have an opinion as to SCHULMAN, CICCARELLI & WIEGMANN 43 Davis - Direct - Parker 1 the specific facility or the level of facility 2 the patient should have been transferred to? 3 A She should have been transferred to a 4 tertiary level facility. 5 Q Do you have an opinion as to when 6 that transfer reasonably would have been 7 accomplished, time of night? 8 A Well, I think they should have been 9 working on getting her out of there within two 10 hours of the time that she appeared. 11 Q Okay. 12 A They should have tried to stabilize her 13 and then transfer her. 14 Q Anything else that if he had been 15 present you would have demanded be done 16 differently in order to comply with the 17 standard of care? 18 A Well, that certainly would have 19 complied. 20 (Whereupon, a discussion is held 21 off the record.) 22 Q Earlier in this deposition as you 23 were explaining to me a little bit about this 24 failure to respond you made comment about 25 needing to alert surgeons. Are you critical of SCHULMAN, CICCARELLI & WIEGMANN 44 Davis - Direct - Parker 1 Dr. Liu for having failed to alert surgeons? 2 A Well, you were asking--there are kind of 3 two things. One is as you go along where were 4 failures made and the other is where did Dr. 5 Liu make errors. 6 The point is if you were caring 7 for this patient, you should have become 8 concerned at 3:50 that you were dealing with 9 the possibility of a patient who now may not be 10 having trouble here but, in fact, is likely to 11 be leaking from a liver capsule. 12 At that point, the phrase I use 13 with the residents is if you walk in bear 14 country, you must be prepared to meet bear. 15 The point is that the bear catcher here is a 16 surgeon, not an OB and I certainly would have 17 alerted--I would have gotten the surgical team 18 on board were I caring for this patient in my 19 facility. 20 I think the standard of care 21 requires that anyone else who elects to take 22 care of this kind of patient would have the 23 same obligation. That's all I'm saying. 24 Q And when did that obligation to 25 alert a surgeon arise? SCHULMAN, CICCARELLI & WIEGMANN 45 Davis - Direct - Parker 1 A Well, it's tentatively arising at 3:50 2 when the patient is complaining of, quote, 3 shoulder cramps. 4 Q Do you have an opinion as to what 5 was causing the shoulder cramps? 6 A Yes. 7 Q Okay. 8 Tell me. 9 A Well, I would agree with what Nurse Nuza 10 said regarding this which raised the question 11 about whether or not this patient was bleeding 12 from her liver. 13 Q Okay. 14 A I think that was a perfectly appropriate 15 thought for her to be having. 16 Q I understood you to state a 17 couple minutes ago that at that point the 18 patient may have been suffering actually a 19 rupture of the hematoma or the intraperitoneal 20 bleed at that point? 21 A Well, I think she was bleeding. I think 22 you have irritation of the diaphragm that is 23 causing this particular symptom. That doesn't 24 mean she was leaking as much as she would be 25 later on. SCHULMAN, CICCARELLI & WIEGMANN 46 Davis - Direct - Parker 1 Q I guess that's what I'm trying to 2 clarify. 3 Do you have an opinion as to 4 whether or not at 3:50 her liver hematoma is a 5 new condition or has the hematoma progressed to 6 a rupture or do we know? 7 A Well, I think we have to assume that she 8 is likely to have had some degree of hematoma 9 which has been present kind of all along, but, 10 you know, the fact that she's got some part of 11 the condition doesn't mean that she's frankly 12 ruptured and hemorrhaging in an uncontrolled 13 fashion. 14 I think at this point all you can 15 say is she's having enough leaking to irritate 16 the diaphragm and obviously at that point you 17 would have to assume that's what you're dealing 18 with and be moving promptly to see about 19 evaluating it and be concerned that you now 20 have the troops available, you know, to counter 21 the complication. 22 Q Do you have an opinion as to how 23 long she had been having liver bleed? 24 A Nothing more specific than that. 25 Q It could have been going on for SCHULMAN, CICCARELLI & WIEGMANN 47 Davis - Direct - Parker 1 days? 2 A Not likely for days. 3 Q Okay. 4 For hours? 5 MR. FRASURE: Before what time? 6 A Not significantly. 7 Q Before 3:50, before we have 8 symptoms. 9 A Yeah. You may have some bleeding before 10 3:50 but in contrast say to an ectopic 11 pregnancy where you can have some bleeding 12 before it reaches the diaphragm, you know, 13 we're talking about something which is right 14 under the diaphragm and I would suspect that 15 the symptomatology from bleeding, if it really 16 is very significant, would be reasonably 17 prompt. 18 Q What is the mortality of a liver 19 bleed in a patient-- 20 A Like this? 21 Q Yes. 22 A The old data would suggest sixty 23 percent. I would be surprised in a patient 24 like this treated promptly if it was over 25 fifteen percent. SCHULMAN, CICCARELLI & WIEGMANN 48 Davis - Direct - Parker 1 Q Why do you say you would be 2 surprised if it was over fifteen percent? 3 A Well, most of the modern data is I 4 think--that I've encountered is kind of 5 anecdotal. I did talk as I said to a liver--I 6 mean, to a trauma surgeon who essentially said 7 that under this set of circumstances, if you 8 were to treat her promptly and she was just 9 bleeding from the capsule rather than a deep 10 rupture, then he would consider this to be--you 11 really shouldn't lose the patient, that you 12 should be successful in controlling the 13 hemorrhage and he would estimate the expected 14 mortality to be no higher than fifteen percent. 15 Q Have you seen any published 16 literature to that effect? 17 A I'm not aware of any. 18 Q Do you know what the mechanism 19 that leads to hepatic rupture during delivery 20 in patients such as this is? 21 A No. I assume that it was a combination 22 of you produce bleeding because of two--a 23 couple factors. One is the actual rupture of 24 arterial sources within the liver and the 25 second is probably infarction related to SCHULMAN, CICCARELLI & WIEGMANN 49 Davis - Direct - Parker 1 inability for oxygen exchange. 2 Q I guess that's getting at what 3 I'm trying to figure out to ask. 4 I have read, and I want to see if 5 you agree, that the chain of events leading to 6 hepatic rupture in delivery begins with hepatic 7 infarction? 8 A Yeah. 9 Q That occurs as a result of 10 complication of preeclampsia? 11 A I think that's correct. 12 Q And that leads, and I want to see 13 if you agree, that leads to neovascularization 14 the affected liver tissue? 15 A I'm not aware that it occurs quite that 16 quickly. Most what we're identifying here I 17 think is going to be occurring within a matter 18 of hours. 19 Q Okay. 20 A I don't think there is any question you 21 can get it later and it may involve that kind 22 of mechanism but I don't think that had any 23 relevance to what went on here. 24 Q Okay. 25 If you do agree, however, that SCHULMAN, CICCARELLI & WIEGMANN 50 Davis - Direct - Parker 1 hepatic infarction is at the beginning of the 2 chain of events, then does that lead to the 3 belief that the hepatic hemorrhage is probably 4 not from a single location but rather is a 5 little more global and systemic in its origin? 6 MR. HIRSHMAN: I am going to 7 interrupt. I don't think you completely 8 characterized what he said. You've taken part 9 of what he said. 10 MR. PARKER: I may not have. I 11 guess that's why I am asking. 12 MR. HIRSHMAN: He said bleeding 13 as well as infarct. With that in mind, go 14 ahead. 15 A If you're asking it as a point of that 16 rather than one which may occupy some 17 appreciable event, the answer is I believe it 18 occupies an appreciable space. Typically I am 19 not aware it is a space so big that you 20 automatically expect liver failure as a 21 consequence thereof. 22 Q Was there any particular 23 treatment that should have been instituted 24 simply because this patient had the low liver 25 function that goes with HELLP Syndrome? SCHULMAN, CICCARELLI & WIEGMANN 51 Davis - Direct - Parker 1 A You mean prior to this? 2 Q Yes, prior to delivery and prior 3 to the rupture. 4 A No, other than being prepared to treat 5 the problem. That's the only thing. 6 Q Your third larger area of 7 criticism was a failure to treat the patient. 8 Have we discussed those specifics? 9 A I thought so. 10 Q I think so, too. I think as I 11 asked follow-up questions, I think I got into 12 that category. If there are other areas in 13 which there was a failure to treat this patient 14 by Dr. Liu, I would like to hear it. 15 A No. Obviously we comment on the fact 16 that there was no one there to respond promptly 17 and I go into the analogy which appears in the 18 current controversy or context of the VBAC. 19 In order to do routine 20 obstetrics, the claim is you are supposed to be 21 prepared to do a cesarean within 30 minutes. 22 Now, there are certain people who have 23 attempted to say we can do VBACs in small 24 community hospitals if we can respond within 30 25 minutes but that's not the intent of the SCHULMAN, CICCARELLI & WIEGMANN 52 Davis - Direct - Parker 1 college. It is not the intent of the 2 profession that that meets appropriate 3 standards. 4 If you do vaginal birth after 5 cesarean, you must be prepared to meet the 6 needs of the patient immediately. There is no 7 30 minute lag time. That's what I'm saying. 8 Here if you actually look at what 9 it took them to go to cesarean, none of the 10 personnel were prepared to respond to this 11 patient's need within 30 minutes of the time of 12 onset of trouble. It took them almost an 13 hour. That doesn't even meet the standard for 14 the conduct of normal obstetrical care in 15 nonhigh risk patients. 16 This was a patient who was 17 clearly a high risk patient. They should have 18 been prepared to operate on this patient 19 immediately if she got into any trouble. They 20 should have been on top of her with regard to 21 having the appropriate people there to take 22 care of her problem and, in fact, you would 23 have to say that she really responded 24 remarkably well at least in some sense to the 25 attempt to stop the bleeding, even though it SCHULMAN, CICCARELLI & WIEGMANN 53 Davis - Direct - Parker 1 had been neglected. 2 That would be another thing that 3 would lead you to say had all this been done at 4 least an hour earlier, you would expect a 5 different outcome. Had there been all of these 6 people there ready to respond immediately to 7 the patient's need, had they been there 8 immediately to say we are apt to have to deal 9 with a bleeding liver, therefore, I don't want 10 to be calling the surgeons when we're in the 11 OR, I want the surgeons there at the time that 12 we have to do something. I want them to be 13 aware of this patient. I want them to be 14 completely on top of doing what is appropriate 15 to be prepared to take care of her. 16 Q Okay. 17 I want to ask you some more 18 questions about what if delivery had been 19 earlier. Before I go there, I want to ask you 20 this: At what point in time did standard of 21 care mandate that this patient be delivered by 22 cesarean section as opposed to vaginal 23 delivery? 24 A Very clearly and certainly at 4:36--this 25 baby should have probably been out by 4:45. SCHULMAN, CICCARELLI & WIEGMANN 54 Davis - Direct - Parker 1 Therefore, at that point they should have known 2 they were dealing with a real problem. 3 Q What is it that happens at 4:36 4 that in your opinion mandates C-section? 5 A She has fetal bradycardia. 6 Q Until 4:36, is it within standard 7 of care to be progressing this patient to 8 vaginal delivery? 9 A Not the way it was done. 10 Q Because the patient should have 11 been referred to a different facility, et 12 cetera? 13 A Well, the point is, during all of this, 14 she wasn't really being cared for. That is the 15 problem. She was on her own kind of up to 16 this. They eventually did start mag and they 17 did put in a Cervidil pessary but, you know, 18 nobody did anything about her blood pressure, 19 you know. That's the whole point. 20 Yes, as long as she was okay, the 21 decision to go for vaginal delivery was not 22 inappropriate and I certainly at no point make 23 that as a claim, but at 4:36, it's apparent 24 that they were playing Mickey Mouse because 25 they were not prepared to move promptly to SCHULMAN, CICCARELLI & WIEGMANN 55 Davis - Direct - Parker 1 rescue this baby. 2 Q You told me a couple minutes ago 3 in your opinion C-section should have been 4 underway at 4:45? 5 A No. The baby should have been out by 6 4:45. 7 Q The baby should have been 8 delivered by 4:45? 9 A Maybe 4:50, you know. 10 Q What would the status of the 11 liver have been at 4:45 or 4:50? 12 A She would almost certainly have been 13 leaking from it. 14 Q Do you have an opinion as to 15 whether or not it would be a subcapsular 16 hematoma at that point or whether it had 17 ruptured at that point? 18 A Well, if she was leaking from it, it 19 would have been ruptured by definition. 20 Q Would antihypertensive medication 21 have had a significant effect on the liver 22 bleed or would that be more directed towards 23 the risks of intercerebral bleed? 24 A I think it would certainly--it is hard 25 to believe that lowering the blood pressure to SCHULMAN, CICCARELLI & WIEGMANN 56 Davis - Direct - Parker 1 a reasonable level would not have decreased the 2 amount of bleeding. 3 Q In all fairness, that sounds like 4 an assumption. 5 A What? 6 Q In all fairness, that to me as a 7 layman sounds like an assumption. Is that an 8 assumption? 9 A Well, from your standpoint, the more 10 likely than not, it meets that criteria. 11 Q Okay. Fair enough. 12 Can you quantify to how much it 13 would have reduced the bleed? 14 A I don't think anyone can but, you know, 15 we're talking about a patient that they 16 estimated twenty-five hundred CCs depending on 17 who is making the estimate, ranging from 18 twenty-five hundred to eight thousand. I mean, 19 the point is it was an appreciable amount. 20 In general, the ground rules are 21 as you get beyond fifteen hundred CCs of 22 bleeding, you are dealing with a patient which 23 is really kind of on the edge of going into 24 shock and we're talking about shock not related 25 immediately to the issue of the actual blood SCHULMAN, CICCARELLI & WIEGMANN 57 Davis - Direct - Parker 1 pressure but to the issue of oxygenating her 2 tissues. 3 As you get beyond that, you are 4 really treading on the patient's survival 5 without injury and that's what my concern is. 6 If you have kept the patient 7 hypertensive until you do that, you have taken 8 away a significant margin of her safety in 9 terms of recovery and that's what my concern 10 is, you know. I can't imagine that she didn't 11 bleed at least two liters--I mean two units, 12 one liter. That's being conservative, during 13 that extra hour. That's being conservative. 14 Q What is your basis for that? 15 A Well, how much did she bleed? I mean, 16 they estimate twenty-five hundred. It's hard 17 to believe that she--there was blood, abundant 18 blood in the abdomen at the time of operation. 19 Patients bleed from livers. You know, if you 20 estimated it much less, what are you estimating 21 it at? 22 There are two possibilities. 23 One, she wasn't bleeding much at all early or, 24 two, she was not accelerating her bleeding but 25 was bleeding at a constant level. In either SCHULMAN, CICCARELLI & WIEGMANN 58 Davis - Direct - Parker 1 case, you get an appreciable amount of 2 bleeding. One, there wouldn't have been much 3 bleeding at all because you were doing the 4 process early. The other is she was bleeding 5 kind of constantly and on a fractional basis, 6 you cut the bleeding time, the amount of time 7 of hemorrhage by an appreciable amount. That's 8 probably at least two units and it probably is 9 considerably more. 10 Q Now I'll show my ignorance. I 11 probably already have multiple times. I'll 12 show my ignorance and ask is there a third 13 possibility. 14 Is there a possibility a previous 15 bleed would have a tamponade effect? 16 A No. 17 Q Why not? 18 A I don't know anybody who thinks these 19 bleed and stop. 20 Q I have to ask. I don't know. 21 A I have not heard anything that these 22 livers in a hypertensive patient can be 23 expected to bleed and stop once they break 24 through. 25 Q If we take a scenario the rapid SCHULMAN, CICCARELLI & WIEGMANN 59 Davis - Direct - Parker 1 bleed occurred in only a few minutes before it 2 was discovered, what can precipitate that kind 3 of rapid bleed in this kind of patient? 4 A Well, eventually the--you know, this is 5 not a very solid thing that is sitting here. 6 It doesn't have the strength of intact tissue. 7 It's kind of when the dam brakes, the dam 8 brakes. 9 Q Would I be correct that even 10 minor trauma like transferring a patient or 11 positioning a patient with that kind of 12 compromised liver could induce a bleed? 13 A It certainly is possible. 14 Q I think I'm ready to move on to 15 my next subject which might go quicker. That 16 has to do with Nurse Nuza. I'm interested in 17 your opinions as to how--I'm sorry, Certified 18 Nurse-Midwife Nuza deviated from standard of 19 care. 20 A Well, I think my paragraph there really 21 pretty well covers it, you know, in all 22 honesty. I don't know a better way of 23 restating it. 24 Q I take it you have nothing--no 25 new opinions with regard to Nurse Nuza that you SCHULMAN, CICCARELLI & WIEGMANN 60 Davis - Direct - Parker 1 need to bring to my attention? 2 A No. 3 Q All right. 4 A I think she was very much trapped by 5 circumstances but her involvement was real 6 because of where she was. 7 Q I am going to infer from our 8 previous discussion that you believe that her 9 duty to insist upon Dr. Liu's personal presence 10 occurred when she first reported the patient's 11 hypertension and proteinuria? 12 MR. HIRSHMAN: Can I have that 13 read back? 14 MR. PARKER: Why don't I just 15 scrap it. Instead of asking the question in 16 that leading question way, let me ask another 17 question. 18 Q You criticize Nurse Nuza for 19 failing to get Dr. Liu personally involved. 20 When was it she was supposed to have done that 21 to comply with the standard of care? 22 A Well, I think the initial contact was 23 at, what did we say, one-thirty or something. 24 Yeah, about one-thirty. So obviously it was 25 there and ongoing because all during this time, SCHULMAN, CICCARELLI & WIEGMANN 61 Davis - Direct - Parker 1 I mean, she was continuing to function I gather 2 in a manner with which she was quite 3 uncomfortable. 4 Q Any other criticisms of her care 5 other than what you have written in your 6 report? 7 A No, not that--I don't believe so. 8 Q All right. I think I asked this 9 but I am going to shoot myself if I didn't. 10 Did this patient have any risk 11 factors for pregnancy induced hypertension, 12 preeclampsia, eclampsia or HELLP Syndrome 13 before her admission for labor and delivery? 14 A I don't know. There is one risk factor 15 that we didn't take up which is I think an 16 aside and that is she is a grand mal/petite mal 17 many times over. I don't believe there 18 may--there may be some implication for 19 hypertension. I am not aware of there being 20 any implication for HELLP Syndrome. 21 Q I have read that hypertensive 22 disease including HELLP Syndrome is responsible 23 for fifteen percent of maternal deaths in the 24 United States. Do you know if that's accurate? 25 A I don't know. It has changed over the SCHULMAN, CICCARELLI & WIEGMANN 62 Davis - Direct - Parker 1 years. At one point it was a big, big problem 2 but years ago, at Parkland Hospital, they 3 launched out to do a massive study on eclampsia 4 and what they found is that the incidence had 5 fallen so dramatically that they were no longer 6 able to do the study that they had planned. 7 I don't know anyone that cried 8 because of that but in general the ones that 9 you lose are often in exactly this category, 10 namely a person particularly of advanced age. 11 There are several kinds of little categories 12 but one of the ones that you're so concerned 13 about are those that develop the syndrome who 14 have advanced maternal age. 15 Q Is hypertensive disease still a 16 major cause of maternal deaths in the United 17 States? 18 A It is a cause but I, you know--other 19 things have taken its place such as anesthesia 20 and it just--it is because the incidence--it 21 has gotten so safe to have a baby that the 22 whole level of maternal death has gone down to 23 such a low level that you're talking about, 24 yeah, it's a significant fraction of those that 25 do die. SCHULMAN, CICCARELLI & WIEGMANN 63 Davis - Direct - Parker 1 Q All right. 2 A But it used to be one of the big three, 3 when the big three were big. 4 Q I hear you saying that childbirth 5 is safer than it used to be. I trust it's not 6 benign, however? 7 A It's not completely benign but it really 8 is down to the point where anesthesia is a 9 major contributor, heart disease, in other 10 words, things that just used to be not a factor 11 at all have moved up into the--into being an 12 appreciable part of the small risks. 13 Q Is there anything a physician can 14 do to prevent pregnancy-induced hypertension? 15 A Not that we know. People have been 16 looking at it. They tried a variety of 17 things. A lot of things have been proposed but 18 I don't know anyone who really believes it. 19 Q Is there anything that a 20 physician can do to prevent the development of 21 HELLP Syndrome? 22 A Not that I'm aware of. 23 Q Doctor, with your permission, I 24 think I have pretty much covered what I need to 25 cover. I will let Mr. Frasure ask you some SCHULMAN, CICCARELLI & WIEGMANN 64 Davis - Cross - Frasure 1 questions and I will review my notes. 2 MR. FRASURE: Can we take a brief 3 break? 4 (Whereupon, a brief recess is 5 taken.) 6 7 CROSS-EXAMINATION BY MR. FRASURE: 8 9 Q Doctor, my name is Mark Frasure. 10 I represent the hospital and Nurse Burton. I 11 think we can wrap this up hopefully in the next 12 25, 30 minutes. 13 You reviewed some depositions 14 before you wrote your letter in the case? 15 A Yes. 16 Q Those include the ones I'm 17 holding here? 18 A Yes. 19 Q You mentioned Nurse Burton that 20 you had reviewed, right? 21 A Right. 22 Q And Midwife Nuza, Dr. Gyves, 23 correct? 24 A Yes. 25 Q I think there are two parts to SCHULMAN, CICCARELLI & WIEGMANN 65 Davis - Cross - Frasure 1 Nuza, Dr. Liu--L-u-i? 2 A It's misspelled there if I recall 3 correctly. 4 Q Is it? 5 A I think it's L-i-u but I think it's 6 L-u-i in there. 7 Q You reviewed this? 8 A That. 9 Q Desiree Marsh, D-e-s-i-r-e-e, and 10 Deborah Amerson? 11 A Well, considering that there is a yellow 12 mark on that, I think the answer is yes. 13 Q Did you place the mark? Is that 14 what you do and it shows you reviewed it? 15 A In that case it was a quick mark what I 16 was dealing with. I don't recall that it 17 was--that I thought it was as pertinent. Here, 18 you can see where I have-- 19 Q You reviewed Desiree Marsh? 20 A Yeah. 21 Q And Deborah Amerson, did you 22 review that also? 23 A You can tell by going through and seeing 24 if there is yellow there. I cannot say that I 25 remember anything particularly from those two SCHULMAN, CICCARELLI & WIEGMANN 66 Davis - Cross - Frasure 1 depositions. 2 Q The more pertinent were Nuza, 3 Burton and Dr. Liu, correct? 4 A Yes, sir. 5 Q Dr. Davis, just so I'm clear, are 6 you subboarded in maternal-fetal? Is that a 7 correct term, subboarded, certificate of added 8 qualifications? 9 A Certificate of special competence is the 10 phrase that's used. 11 Q When were you--when did you 12 receive that in maternal-fetal? 13 A '74. 14 Q What size hospital are you 15 affiliated with here at Hackensack Medical 16 Center? 17 A I believe it's 630 beds. 18 Q And you have been-- 19 A Thereabouts. 20 Q You have been with the hospital 21 how long? 22 A Six years. 23 Q Are you employed by the hospital? 24 A Yes. 25 Q What is your title? SCHULMAN, CICCARELLI & WIEGMANN 67 Davis - Cross - Frasure 1 A I'm section chief of maternal-fetal 2 medicine. 3 Q Before the six years, you were in 4 private practice? 5 A No. 6 Q Okay. 7 A Maternal-fetal people are seldom in 8 private practice in the same sense that others 9 are. 10 Q Right. 11 A Before then, I was codirector of 12 perinatology at Morristown Memorial Hospital, a 13 very comparable hospital to this. It's about 14 the same size. 15 Q Okay. 16 A Before that, I was with the Robert Wood 17 Johnson Medical School. 18 Q In New Jersey? 19 A In New Brunswick. 20 Q I need to ask you this question: 21 Have you ever had your license suspended or 22 revoked for any reason? 23 A No. 24 Q Ever had your privileges 25 suspended, revoked or curtailed at any SCHULMAN, CICCARELLI & WIEGMANN 68 Davis - Cross - Frasure 1 hospital? 2 A No. 3 Q You mentioned a little bit on the 4 medical-legal review. On average, let's say in 5 a given year's time, how many cases do you get 6 in to review before you give depositions, just 7 get in to look at? 8 A Well, it depends on--usually what will 9 happen is this. 10 Q Not phone calls but actual 11 records. 12 A Oh. 13 Q Records and depositions. 14 A Maybe as many as 20, 25, something like 15 that. 16 Q A year? 17 A Yeah. 18 Q That's been approximately the 19 rate for the last how many years? 20 A I don't know. I think there were two or 21 three years it went way down for reasons I 22 didn't particularly understand. I don't 23 understand why it has gone up-- 24 Q Sure. 25 A --now but that would be reasonable. A SCHULMAN, CICCARELLI & WIEGMANN 69 Davis - Cross - Frasure 1 good year would still be about that. It 2 wouldn't be much more than about 30 I would 3 think. 4 Q What is the typical breakdown? 5 Is it 80/20, plaintiff/defense? 6 A Well, if you were to go back many years, 7 it would be almost no plaintiffs--I mean, no 8 defense. Now it's more likely to be I think in 9 the range of probably about, what, five out of 10 six would be plaintiffs. 11 Q How long has that been true, 12 would you say? 13 A Probably three to five years, maybe 14 seven years. As I said, I don't keep up with 15 it. 16 Q Okay. 17 A Time, as you know, passes without 18 sending out notice. 19 Q Of the various cases you have 20 reviewed, do you recall reviewing any other 21 HELLP Syndrome cases involving--and let me 22 narrow it down further, HELLP Syndrome with 23 liver hematoma? 24 A I don't remember any. 25 Q Okay. SCHULMAN, CICCARELLI & WIEGMANN 70 Davis - Cross - Frasure 1 A Which is not to say it didn't happen but 2 I don't remember any. 3 Q Am I correct that you can have 4 HELLP Syndrome-- 5 A Yes. 6 Q --without having the liver 7 hematoma? 8 A Absolutely. 9 Q And most of the HELLP cases don't 10 have the liver hematoma? 11 A Absolutely. 12 Q Is that right? 13 A That is correct. 14 Q If you had your druthers, you 15 would not ever want to have HELLP with the 16 liver hematoma? 17 A Absolutely. 18 Q The prognosis is worse when you 19 have the liver hematoma than if you don't, 20 correct? 21 A Yes. 22 Q Sure. Okay. 23 Have you had any patients die who 24 had HELLP Syndrome or HELLP with liver 25 hematoma? SCHULMAN, CICCARELLI & WIEGMANN 71 Davis - Cross - Frasure 1 A We've had--I had a patient many years 2 ago that died not specifically related to that 3 but related to one of the allied conditions. 4 We didn't understand it at the time, so-called 5 antiphospholipid syndrome. It was in the early 6 '80s. 7 It was not well defined in the 8 literature and certainly none of us understood 9 it at the time but that's what she did die of. 10 I think in retrospect that's what it looked 11 like. 12 Q Dr. Davis, are you able to 13 estimate what percentage of HELLP cases 14 actually have the liver involvement, liver 15 hematoma? 16 A Not really. I think it would be under 17 five percent. You're talking about in terms of 18 rupture? 19 Q Well, can you have a liver 20 hematoma that doesn't go on to rupture? 21 A Yes. 22 Q Am I correct just the fact of 23 having a hematoma says that the liver has been 24 bleeding? 25 A Into itself. SCHULMAN, CICCARELLI & WIEGMANN 72 Davis - Cross - Frasure 1 Q Into itself. Right. 2 A But there is a big difference in having 3 it bleed into itself and having it bleed, to 4 break through to bleed into the abdomen. 5 Q I understand. 6 Just so I'm clear then, when we 7 said earlier most HELLP patients do not have 8 liver hematoma, do we mean most HELLP patients 9 don't even have bleeding within the liver 10 itself? 11 A Not significant amounts of it. 12 Periportal hemorrhage is I think seen with some 13 frequency in, quote, preeclampsia, particularly 14 if it's severe, but you don't get the 15 coalescing of this to form a significant 16 problem. That's unusual. 17 Q If we focus for the moment on 18 HELLP cases that have liver hematoma, liver 19 bleeding, even just within itself, in a given 20 year how many of those cases might you be 21 involved with? 22 A I wouldn't be involved with one in I 23 think probably every five years. 24 Q Pretty rare? 25 A It's a rare event. SCHULMAN, CICCARELLI & WIEGMANN 73 Davis - Cross - Frasure 1 Q The HELLP with the liver 2 hematoma? 3 A Yeah. 4 Q Okay. 5 A Clinically significant. 6 Q Sure. I understand. 7 You mentioned I think at some 8 point this was a full blown case of HELLP with 9 liver involvement? 10 A Right. 11 Q When did it become full blown? 12 Are you saying it became full blown only late 13 in the morning hours or was it full blown 14 basically initially? 15 A Well, I think she--it's reasonable to 16 suppose that she had significant hemorrhage 17 into the substance of the liver. If one wants 18 to claim it was from the early hours, I 19 wouldn't take issue with that. 20 Q Okay. 21 A But I don't believe that it began to 22 leak significantly prior to 3:50 in the 23 morning. 24 Q And you base that on what, now, 25 the 3:50? SCHULMAN, CICCARELLI & WIEGMANN 74 Davis - Cross - Frasure 1 A Symptomatology. 2 Q The shoulder pain? 3 A Yeah. 4 Q I thought most HELLP patients 5 that have clinical pain, it's in the epigastric 6 area? 7 A Right. 8 Q How do you get that to the 9 shoulder? 10 A It has to do with irritation of the 11 phrenic nerve. 12 Q Like radiation in effect? 13 A It's the same thing as you get with 14 ectopic pregnancy where a patient may complain 15 of shoulder pain. 16 Q Is shoulder pain pretty typical 17 for a patient that has HELLP with liver 18 involvement? 19 A It's pretty typical of patients that 20 have bleeding into the abdomen. 21 Q Nurse Burton noted that in the 22 records, did she not, the shoulder pain? 23 A Right. 24 Q That was appropriate to do? 25 A Completely. SCHULMAN, CICCARELLI & WIEGMANN 75 Davis - Cross - Frasure 1 Q Now, you fault her because she 2 should have done more than note it? 3 A Yes. 4 Q What should she have done? 5 A She should have let others know that the 6 patient was making that complaint. 7 Q Would you expect that if that 8 shoulder pain were symptomatic as you say I 9 think of the bleeding, would the shoulder pain 10 have persisted, continued over time, the amount 11 of time she was conscious? 12 A Well, it certainly would raise--yeah. 13 You would expect it to be a problem. 14 Q Now, if the doctor had been in as 15 you say he should have-- 16 A Yes. 17 Q --attending to the patient, can 18 we agree that this complaint of shoulder pain 19 had it persisted beyond just initially would 20 have been observed by a physician? 21 A It should have been. 22 Q Okay. 23 Is that basically then the only 24 standard of care criticism you have of Nurse 25 Burton? I'll move on if it is because that's SCHULMAN, CICCARELLI & WIEGMANN 76 Davis - Cross - Frasure 1 all I saw in the report. 2 A Well, there is--the problem is that, and 3 it's not a specific criticism of her because I 4 don't know where you aim it, but normally in a 5 place like this, if a nurse is not comfortable 6 with what a doctor is doing, it is understood 7 that she is supposed to report to a superior 8 her lack of comfort. 9 Q Okay. 10 A We don't find any evidence of that. So 11 that is really what we would complain of. 12 Where the hospital stops and Nurse Burton does, 13 it's not completely clear because I don't 14 know--could not tell from this what is the 15 chain of command for a very sick patient that 16 you're not comfortable with what is happening 17 with for the hospital. 18 There should be the ability of 19 the hospital to produce some sort of coherent 20 policy in terms of what a nurse does if she's 21 not comfortable. 22 Q Are you saying then Nurse Burton 23 should have done something more to go up the 24 chain of command? 25 A Well, the way it is, what I identify is SCHULMAN, CICCARELLI & WIEGMANN 77 Davis - Cross - Frasure 1 she didn't tell nurse--the certified nurse. 2 Q Nuza? 3 A Is it Nuza? Do you put a T in there? 4 MR. HIRSHMAN: I think it's Nurse 5 Nuza. 6 A Whoever she is. 7 Q What should she have done? 8 A The standard thing would have been she 9 would report to someone. As I understand it, 10 in contrast to what would normally be, namely 11 that you would end up with a certified 12 nurse-midwife to be part of the hospital 13 structure and it would go up that way, that 14 she, in fact, is part of the doctor's 15 structure. 16 Q The midwife? 17 A The midwife and hence she's kind of free 18 floating for any kind of access to the 19 administration and-- 20 Q Who is she now? 21 A Burton, in terms of having someone to 22 report to-- 23 Q Okay. 24 A --if she's uncomfortable with what is 25 going on. SCHULMAN, CICCARELLI & WIEGMANN 78 Davis - Cross - Frasure 1 Q Did you sense she was 2 uncomfortable from her deposition or do you 3 recall? 4 A I don't remember enough about it 5 immediately to answer that question. 6 Q What if we factor in Dr. Liu is 7 the chairman of the obstetrical department and 8 he's the one who is on the phone? Does that 9 complicate the chain of command issue? 10 A No, because theoretically she shouldn't 11 be complaining to him. She should be 12 complaining to a nurse supervisor. 13 Q Oh, I see. 14 A The nurse supervisor is the one that 15 would relate at some level to Dr. Liu. 16 Q Okay. 17 In that kind of situation, just 18 hypothetically, if the nurse supervisor calls 19 Dr. Liu and says, "You really should get in," 20 and if Dr. Liu says, "No, I think we have it 21 under control," and he's the head of the 22 department, what happens then? What should 23 happen or is there anything? 24 A Well, usually what would happen is it 25 would depend on--you know, if somebody looks at SCHULMAN, CICCARELLI & WIEGMANN 79 Davis - Cross - Frasure 1 this and says, you know, I'm not--you may be 2 the chairman but you're involving this hospital 3 in terms of liability, therefore, you start 4 bringing more persuasive voices in. 5 Q All right. 6 You're saying it should have been 7 done here? 8 A I'm saying that would have been 9 appropriate. 10 Q When would it have been 11 appropriate to do that, approximately what 12 time? 13 A Well, when you saw that the patient was 14 not being cared for by Dr. Liu. 15 Q He was giving orders and he was-- 16 A She was not being cared for. 17 Q Are you aware he said in his 18 deposition he feels he was appropriately kept 19 informed of the patient's status? 20 A I think I have been pretty 21 straightforward here-- 22 Q I understand. 23 A --of my criticism of Dr. Liu. I find 24 nothing about Dr. Liu's behavior that could be 25 considered defensible in any department I have SCHULMAN, CICCARELLI & WIEGMANN 80 Davis - Cross - Frasure 1 ever been a member of. 2 Q You explained that. 3 When should Nurse Burton have 4 sensed or said to herself, "You know, Dr. Liu 5 is not doing something here that is really 6 worrying me. I should go up to the next 7 level." 8 What was it that should have 9 first caused her to do that, coming in after 10 the labs are drawn that show the bad platelets? 11 A Yeah, certainly by that point. The 12 point everyone should be aware of is this is 13 not a patient for a certified nurse-midwife to 14 be taking care of. 15 Q Let me ask you then about the 16 whole issue of the nurse-midwife. 17 Have you been affiliated with any 18 hospitals that have nurse-midwives on staff? 19 A I have. 20 Q You have? 21 A Yes. 22 Q That's pretty common, isn't it? 23 A No, not around here. I think they're 24 wonderful. 25 Q Okay. SCHULMAN, CICCARELLI & WIEGMANN 81 Davis - Cross - Frasure 1 A I am not anti nurse-midwife. In fact, 2 I've been kind of surprised that the insurance 3 companies--the logical way to take care of 4 normal obstetrical patients is really with 5 certified nurse-midwives backed by 6 perinatologists if you wanted the biggest bang 7 for the buck. Unfortunately, the generalist is 8 in that area in which they're overtrained for 9 routine obstetrics and undertrained for 10 everything that goes wrong and we're getting to 11 the point if you look around, what happens in 12 most major metropolitan areas, if you have a 13 real complication, the standard of care that is 14 applicable is the standard of care of a 15 perinatologist because we're not talking about 16 South Dakota, you know. 17 We're not talking about an area 18 where you may go a long distance before you get 19 someone. There are so many certified high risk 20 specialists now-- 21 Q You mean geographical area? 22 A Geographical. 23 --that it's very hard to defend 24 compromising care because they're available. 25 Q Are you saying that the hospital SCHULMAN, CICCARELLI & WIEGMANN 82 Davis - Cross - Frasure 1 should have had a perinatologist on staff? 2 A No. I'm not saying that. 3 Q All right. I understand. 4 A No, not at all. I'm saying that in the 5 absence of that, it should have defined very 6 carefully what its role was and the care of 7 this patient was not as near as I can tell any 8 longer within the role of what this hospital 9 ought to be doing. 10 Q Because of no perinatologist? 11 A And, you know, if you have got doctors 12 that don't believe that they ought to be in 13 when they're caring for someone this sick, I 14 mean, that's all right. I don't have any 15 problem with that. I do have a problem with 16 thinking that when you have got very good, well 17 respected tertiary care hospitals in the area 18 as they exist in Cleveland, that this kind of 19 patient should have been cared for in other 20 than that kind of setting. That's what-- 21 Q Speaking of perinatologists, am I 22 correct that is synonymous with a 23 maternal-fetal specialist? 24 A And high risk. Those all mean the same 25 thing. SCHULMAN, CICCARELLI & WIEGMANN 83 Davis - Cross - Frasure 1 Q It's my understanding, and maybe 2 I'm wrong, Dr. Gyves, G-y-v-e-s, is a 3 maternal-fetal specialist? 4 A If he is, I don't know it. 5 Q Okay. All right. 6 So as I look at your report, the 7 criticism then of the hospital basically is 8 that they weren't prepared to respond quickly 9 to a surgery need? 10 A Well, to a diagnostic need. I mean, 11 they did--it's very clear that a person who 12 understood what was going on at that point was 13 not linked up with this patient. 14 Q If Dr. Liu had been in and if he 15 had responded as you believe he should have, 16 would there have been time to avoid the 17 problem? 18 A No, but there would have been time to 19 take care of the problem. 20 Q Even though there may not be a 21 perinatologist on staff at this hospital? 22 A Right. It's just much riskier if you're 23 dealing with someone who is less apt to know 24 what he's dealing with. 25 Q I see. SCHULMAN, CICCARELLI & WIEGMANN 84 Davis - Cross - Frasure 1 A For example, shortly after I got here, I 2 was asked to look at a patient at 25 weeks who 3 came in with pre-term labor, horrible 4 decelerations going on. I took a brief history 5 and began to ask a couple other questions and 6 my immediate comment was, "This looks like 7 Listeria to me," and of course everyone else 8 says, "What?" 9 The point is not that a 10 maternal-fetal person knows Listeria. It is 11 that a maternal-fetal person is supposed to 12 know about that and be able to do that sort of 13 thing-- 14 Q Okay. 15 A --whether it's rare or not. A 16 maternal-fetal person would not need to go to 17 the library to find out and be reading about 18 this condition. A maternal-fetal person should 19 know enough to be able to know what was 20 appropriate and what was needed to take care of 21 this person. 22 Q I understand what you're saying. 23 Dr. Liu I believe testified that 24 he was--he felt that the patient probably had 25 HELLP Syndrome even as he was taking the calls SCHULMAN, CICCARELLI & WIEGMANN 85 Davis - Cross - Frasure 1 from at home. 2 A Right. 3 Q You're saying he did not 4 appropriately treat it once he had information 5 that should have told him that it was HELLP? 6 A Right. I mean, this was not an 7 appropriate way of handling the patient. 8 Q If he had come in and if he had 9 handled the patient appropriately, is there any 10 reason to think that treatment couldn't have 11 been instituted within a reasonable time after 12 his decision to institute it that would have 13 led to a different outcome? 14 A The only thing I can think of in terms 15 of--to answer your question, I believe you're 16 asking had someone who understood what he was 17 seeing been able to have-- 18 Q Right. 19 A --altered the outcome without 20 transferring the patient. In all likelihood, 21 that could have been done. 22 Q At that hospital? 23 A At that hospital. 24 Q Okay. 25 A But it is done with more danger of it SCHULMAN, CICCARELLI & WIEGMANN 86 Davis - Cross - Frasure 1 happening than what happened rather than having 2 it picked up because there was someone there 3 who really understood the implications more 4 deeply. 5 Q Okay. I follow you. 6 Staffing of the hospital, is your 7 criticism they should have been able to have 8 surgical people in sooner once a decision is 9 made that this patient is going to go to 10 surgery at that time of the evening? 11 A No. What I'm saying is that I'm not 12 aware that they made a big delay in terms of 13 the hospital. The problem was without 14 understanding the limitations, you end up with 15 an inappropriate person directing the care and, 16 therefore, there is not the coordination that 17 would have produced a different outcome-- 18 Q I see. 19 A --occurring. That's what I'm saying. 20 Q So it's not the fact that the 21 hospital didn't have residents that really made 22 any difference here? 23 A No. No. 24 Q All right. 25 You mention an ultrasound you SCHULMAN, CICCARELLI & WIEGMANN 87 Davis - Cross - Frasure 1 believe should have been done, correct? 2 A Yes. 3 Q At about 3:50 or thereabouts? 4 A Well, they should have been moving to do 5 t. 6 Q Before then or at around that 7 time? 8 A No, at that time. 9 Q How about a CAT scan of the 10 abdomen or the liver, that should have been 11 done? 12 A Probably not. Probably not. It's the 13 sort of thing you would do if she wasn't 14 pregnant. 15 Q Why is it, because of the 16 radiation issues? 17 A Yes. 18 Q Are there also concerns about 19 moving her to the scanner? 20 A No. You should be concerned about 21 having a patient who may be actively bleeding. 22 Q Am I correct that you're saying 23 if the antihypertensive drugs had been given, 24 that probably would have resulted in 25 significantly less bleed from the hematoma? SCHULMAN, CICCARELLI & WIEGMANN 88 Davis - Cross - Frasure 1 A And insult to the brain. The brain 2 would have been more tolerant of the insult 3 from the bleed and the insult from the bleed 4 would have been less because the amount of 5 blood loss would have been less. 6 The physiologic insult then would 7 have been reduced because the amount of blood 8 loss would have been less and in addition to 9 that--I was also including and the time would 10 have been moved up. That's the point. You 11 would be dealing with a patient in 12 significantly better condition. 13 Q One part of that I didn't 14 follow. 15 A Okay. 16 Q Something about less insult to 17 the brain would have caused less blood loss, to 18 paraphrase. 19 A No. No. The point is that less insult 20 to the brain, edema, et cetera, the impact on 21 the brain when you get hypotension would have 22 been significantly less. Also, the amount of 23 hypotension and that insult would have been 24 terminated because the amount of bleeding-- 25 Q Would have been less? SCHULMAN, CICCARELLI & WIEGMANN 89 Davis - Cross - Frasure 1 A --that would have occurred to produce 2 the insult would have been reduced. That's 3 what I am saying. 4 Q Did the patient have a stroke? 5 Are you saying that she had a stroke? 6 A I don't know that you could call it a 7 stroke because it was more generalized. We 8 normally think of stroke as a loss of some 9 specific area of the brain. As near as I can 10 tell, this is kind of a much more diffuse 11 process. 12 Q If the antihypertensives had been 13 given-- 14 And you believe they should have 15 been started what, around two p.m.--two a.m.? 16 A Essentially immediately. 17 Q --would that have allowed more 18 likely than not the patient to be delivered 19 vaginally? 20 A I don't know. I consider that kind of 21 irrelevant, you know. At some point this 22 patient would have needed to be operated on and 23 someone would have needed to have assessed 24 whether or not there was blood in the abdomen. 25 If you were successful in getting SCHULMAN, CICCARELLI & WIEGMANN 90 Davis - Cross - Frasure 1 her delivered vaginally, you would still at 2 some point need to involve probably both a GI 3 and a surgeon in terms of the issue of what was 4 going on in this liver. 5 Q Are you saying then, Doctor, that 6 the patient necessarily--automatically or 7 necessarily needed an earlier C-section to 8 handle HELLP with the liver hematoma? 9 A No. I'm saying that it turned out that 10 the diagnosis was made only when an incision 11 was made in the abdomen. If you were 12 successful in avoiding an incision in the 13 abdomen, at some point someone would have 14 needed to resolve the issue of bleeding in the 15 liver. That would have likely involved both a 16 GI person and a general surgeon who would have 17 made the issue about I'm comfortable waiting, 18 I'm not comfortable waiting. We need to 19 understand whether there's blood in the abdomen 20 and, if so, how much. 21 Once the baby is delivered, if 22 the patient is stable, you may make a variety 23 of other decisions regarding how you go about 24 answering that question, and I wouldn't--it 25 would be highly dependent on the stability of SCHULMAN, CICCARELLI & WIEGMANN 91 Davis - Cross - Frasure 1 the patient and what they were prepared to do. 2 Q Because I know there's a point of 3 view I think within the school of HELLP or this 4 was from Dr. Weinstein that early cesarean 5 section is the treatment of choice for HELLP. 6 Is that what you're saying here necessarily? 7 A Well, certainly early delivery would 8 have been. I think at that point--I don't 9 think there's any question that delivery has 10 always been understood to be the best way of 11 treating the preeclamptic complex of disease 12 and the more serious the circumstances, then 13 the more desirable terminating the pregnancy 14 is. I can't argue with that. 15 There are other people who have 16 argued that if you can stabilize the patient, 17 and there is some people even now that advocate 18 if you treat them with steroids, you may be 19 able to stabilize the process long enough to 20 get a significant more amount of time. 21 I have no--I am aware of the 22 argument. I have no real opinion other than 23 noting that it exists. 24 Q Let me go back then on the issue 25 of the delivery. Dr. Liu I think said in his SCHULMAN, CICCARELLI & WIEGMANN 92 Davis - Cross - Frasure 1 deposition that he wanted the patient to be 2 delivered and he was trying to induce her with 3 the Cervidil? 4 A Uh-huh. 5 Q In and of itself, was the using 6 of the Cervidil incorrect? 7 A No. It may have been unreasonably 8 hopeful but not immediately obvious. The 9 problem I have, it has to do with stabilization 10 of the patient at which point you make a 11 decision as to whether or not you're likely to 12 be successful. 13 This is a patient that was--some 14 people would fault him for using a 15 prostaglandin in a patient with this many 16 deliveries in her history. 17 Q But that had nothing to do with 18 the outcome here, did it? 19 A But that had nothing to do with the 20 outcome. I would not argue one way or the 21 other because the Cervidil can be, in fact, 22 pulled. 23 Q Right. 24 A So if they were to elect to use it, 25 that's all right, but the important thing is it SCHULMAN, CICCARELLI & WIEGMANN 93 Davis - Cross - Frasure 1 must be done in a stable patient and it must be 2 abandoned if you have evidence that that 3 stability is lost. 4 Q Okay. 5 Am I hearing you say that 6 antihypertensive medicines need to be given 7 right away? 8 A Right. 9 Q And you think that would likely 10 have happened here with the institution of that 11 and the treatment by a physician in place would 12 have likely resulted in a stabilization of the 13 patient? 14 A Yes. 15 Q That would have led to a better 16 choice of whether to go vaginal or cesarean 17 section in light of knowing what the situation 18 was? Is that basically-- 19 A Yeah. I think it's always better to 20 operate on a stable patient. 21 Q And the bleeding in your opinion 22 from the liver-- 23 A Yes. 24 Q --the frank bleeding we'll call 25 it-- SCHULMAN, CICCARELLI & WIEGMANN 94 Davis - Cross - Frasure 1 A Right. 2 Q --would probably have been 3 considerably less had the patient been given 4 antihypertensives? 5 A And might have been delayed. You see, 6 that's the point. 7 Q Delayed to the point maybe 8 vaginal delivery could have occurred? 9 A That's touch and go. 10 Q A close call? 11 A I mean in terms of that but it would 12 have been a reasonable time course to hope 13 for. That's all I'm saying. 14 Q Let me jump ahead to the fetal 15 bradycardia that was discovered around 4:40 or 16 approximately. 17 A 4:36, wasn't it? 18 Q Yes. 19 Are you contending that a lower 20 fetal heart rate--excuse me, bradycardia should 21 have been discovered before then and that it 22 was going on before then? 23 A No. 24 Q Okay. 25 A No. I wasn't implying that at all. SCHULMAN, CICCARELLI & WIEGMANN 95 Davis - Cross - Frasure 1 Q I didn't think you were. 2 What is causing the fetal 3 bradycardia in hindsight? 4 A The presumption is she's now 5 becoming--she's now beginning to shift her 6 blood flow to maintain-- 7 Q Herself? 8 A Yeah. 9 Q Now you mentioned from fetal 10 bradycardia, obviously you need to get to a 11 cesarean section quickly? 12 A At this point, yes. 13 Q The baby turned out to be okay? 14 A Well, an Apgar of 2. 15 Q I believe there is no claim being 16 brought. 17 A No. No. I'm not saying there is. 18 Q Right. 19 A If they can get this excited in this 20 town about someone throwing a bat off to the 21 side that didn't hit anyone, I believe-- 22 Q That is not Cleveland. That was 23 New York. 24 A I know. That's what I said, in this 25 town. SCHULMAN, CICCARELLI & WIEGMANN 96 Davis - Cross - Frasure 1 Q Okay. 2 A I don't think I have a right to be 3 excited about anything that produces a baby 4 with an Apgar of two. 5 Q I understand. 6 A The fact that the baby recovered and 7 suffers no permanent damage from this, we'll 8 take any luck we can get but if you end up 9 producing an insult like this and you get away 10 with it, it doesn't prove it wasn't an insult. 11 Q The reason behind my question, I 12 heard from people that the 30 minutes from 13 decision to incision is basically for the 14 baby's protection, of course. Is that 15 generally true? 16 A Generally true but it may be for more 17 than that. I mean-- 18 Q Did it hurt the mother here if it 19 took more than 30 minutes-- 20 A I believe it did. 21 Q --from decision to incision? 22 A I believe it did. She was bleeding. 23 Q All right. 24 Dr. Liu said in his deposition 25 that he thought antihypertensives would have SCHULMAN, CICCARELLI & WIEGMANN 97 Davis - Cross - Frasure 1 been contraindicated because they could likely 2 have taken blood supply away from the baby. 3 You disagree with that observation or opinion? 4 A Yeah. 5 Q I thought you did. I just wanted 6 to be sure. 7 A Yeah. 8 Q Have we covered your opinions 9 against the doctor--excuse me, against the 10 hospital and Nurse Burton that are essentially 11 mentioned in your report then? 12 A I'm under the impression that we have 13 covered that. I don't believe I have other 14 issues that have been added since that. I 15 think I discussed everything with you. 16 Q When in your opinion did the 17 standard of care--would the standard of care if 18 followed have resulted in a diagnosis that the 19 patient had a hematoma on her liver? 20 At what time should that have 21 been known to the physician? 22 A Well, that's hard to absolutely say. 23 Certainly by the time you were talking about, 24 3:50, you ought to be thinking in terms of 25 seeing what you could see. That's all I'm SCHULMAN, CICCARELLI & WIEGMANN 98 Davis - Cross - Frasure 1 saying. 2 Q By 3:50, was the patient's course 3 reversible? 4 A What do you mean by reversible? 5 Q Would she have recovered from the 6 liver hematoma? Would it not have ruptured? 7 A Oh, I would suspect it would have gone 8 on to rupture. That is not the issue. 9 The issue in terms of that, as I 10 said, if you had had people in place ready to 11 move and done the C-section at the time that 12 the baby complained and immediately taken care 13 of both mother and baby, I think the mother 14 would have survived all of this and recovered. 15 Q Do you know Dr. Sibai? 16 A I do. 17 Q Have you gone to any lectures 18 that he has given on the subject of HELLP or 19 attended anything like that? 20 A I've been listening to him on and off 21 for a significant number of years, yeah. 22 Q You recognize him as one of the-- 23 A Significant contributors to the 24 literature. 25 Q In the field of HELLP? SCHULMAN, CICCARELLI & WIEGMANN 99 Davis - Cross - Frasure 1 A Yeah. 2 Q You read his report here? 3 A I have. 4 Q Have you heard of the--one of the 5 experts for Dr. Liu, Dr. Ashmead-- 6 MR. PARKER: Ashmead. 7 Q --of Cleveland Metro in 8 Cleveland? 9 A I don't know him. 10 Q I think he's maternal-fetal 11 also. 12 A Yeah. I would imagine he is. 13 Q Do you know Dr. Gatewood, one of 14 the experts for the plaintiff? 15 A Yeah. I know Dr. Gatewood or know of 16 him. 17 Q How do you know of him? 18 A Well, he is kind of one of the ongoing 19 jokes in this area. 20 Q Which Gatewood are we talking 21 about? 22 A I assume that we're talking about the 23 Gatewood that testifies--I think he was trained 24 in London or something like that. 25 Q Paul Gatewood formerly of Akron, SCHULMAN, CICCARELLI & WIEGMANN 100 Davis - Cross - Frasure 1 Ohio? 2 A Then we're not talking about the same 3 one. There is a Dr. Gatewood you probably 4 encountered previously. 5 Q Paul Gatewood of Ohio, you do not 6 know him? 7 A No. I don't know him. 8 Q He's not maternal-fetal. I think 9 he's OB. 10 A Maybe. Is he an elderly gentleman? 11 Q No. 12 A Then he's not the same one. 13 Q Fair enough. I think that's all 14 I have. We will get out of here. 15 A Okay. 16 17 REDIRECT EXAMINATION BY MR. PARKER: 18 19 Q I have a couple follow-ups. 20 Sorry to ask but I would be derelict in my 21 duties if I didn't. 22 Have you ever been named as a 23 defendant in a medical negligence suit? 24 A Yes. 25 Q On how many occasions? SCHULMAN, CICCARELLI & WIEGMANN 101 Davis - Redirect - Parker 1 A Sorry? 2 Q On how many occasions? 3 A Let's see. You mean that were resolved 4 in-- 5 Q Just named. 6 A I think it may have been three or four, 7 something like that. 8 Q Have any ever gone to trial? 9 A None of them have gone to trial. 10 Q Are any currently pending? 11 A One is currently pending. 12 Q Have you ever testified as a 13 medical-legal expert in any cases involving 14 HELLP Syndrome? 15 A I didn't hear your question. 16 Q Have you ever testified in 17 any--as a medical-legal expert in any case 18 involving HELLP Syndrome before this one? 19 A I thought that was asked earlier. 20 MR. FRASURE: He is narrowing it 21 down to testifying. 22 A I thought I answered no in that case 23 which would make it unlikely-- 24 Q I must have had my attention 25 averted at that time. Thank you very much. SCHULMAN, CICCARELLI & WIEGMANN 102 Davis - Redirect - Parker 1 (Whereupon, the witness is 2 excused.) 3 (Whereupon, the deposition is 4 concluded at 3:22 p.m.) 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SCHULMAN, CICCARELLI & WIEGMANN 103 1 C E R T I F I C A T E 2 3 4 I, GAIL D. MILLARES, a Certified 5 Shorthand Reporter and Notary Public of the 6 State of New Jersey, certify that the foregoing 7 is a true and accurate transcript of the 8 stenographic notes of the deposition of said 9 witness who was first duly sworn by me, on the 10 date and place hereinbefore set forth. 11 I FURTHER CERTIFY that I am 12 neither attorney, nor counsel for, nor related 13 to or employed by, any of the parties to the 14 action in which this deposition was taken, and 15 further that I am not a relative or employee of 16 any attorney or counsel employed in this case, 17 nor am I financially interested in this case. 18 19 20 21 GAIL D. MILLARES, C.S.R. 22 LICENSE NO. XIO1891 23 24 25 SCHULMAN, CICCARELLI & WIEGMANN