0001
 1   The State of Ohio,  )
 2   County of Cuyahoga. )  SS:
 3            IN THE COURT OF COMMON PLEAS
 4   Mary Williams, etc., et al.,)
 5            Plaintiffs,        )Case No.
 6            -vs-               )406184
 7   Parma Community General     )
 8   Hospital, et al.,           )
 9            Defendants.        )
10                  - - - o0o - - -
11       Deposition of METHOD DUCHON, M.D., an
12   expert witness herein, called by the
13   Plaintiffs as if upon cross-examination
14   under the statute, and taken before Luanne
15   Stone, a Notary Public within and for the
16   State of Ohio, pursuant to the agreement of
17   counsel, and pursuant to the further
18   stipulations of counsel herein contained, on
19   Saturday, the 2nd day of June, 2001 at 11:00
20   o'clock A.M. at the offices of Weston, Hurd,
21   Fallon, Paisley & Howley, 2500 Terminal
22   Tower Building, the City of Cleveland, the
23   County of Cuyahoga and the State of Ohio.
24   
25   
0002
 1   APPEARANCES:
 2             On behalf of the Plaintiff:
 3             Nurenberg, Plevin, Heller &
 4             McCarthy, by:
 5             William Jacobson, Esq.
 6             David M. Paris, Esq.
 7   
 8             On behalf of the Defendant,
 9             Parma Community General
10             Hospital:
11             Weston, Hurd, Fallon, Paisley
12             & Howley, by:
13             John Jeffers, Esq.
14   
15             On behalf of the Defendant,
16             The Women & Wellness Center and
17             William Hahn, M.D.:
18             Bonezzi, Switzer, Murphy &
19             Polito, by:
20             Kevin Kadlec, Esq.
21   
22             On behalf of the Defendant,
23             Physicians Staffing:
24             Hanna, Campbell & Powell, by:
25             Jeffrey E. Schobert, Esq.
0003
 1               P R O C E E D I N G S
 2         METHOD A. DUCHON, M.D., being of
 3   lawful age, having been first duly sworn
 4   according to law, deposes and says as
 5   follows:
 6   CROSS-EXAMINATION OF METHOD A. DUCHON, M.D.
 7   BY MR. JACOBSON:
 8   Q    Good morning, Doctor.
 9   A    Good morning.
10   Q    Doctor, my name is Bill Jacobson.  I'm
11   one of the attorneys representing the
12   plaintiffs.  I'll be asking you some
13   questions today about yourself as well about
14   your knowledge of the Williams matter.  If I
15   don't make myself clear, or if you don't
16   understand the question, please let me know,
17   and I'll try to rephrase it so that you do
18   understand, okay?
19   A    Yes.
20   Q    Doctor, you've authored a report of
21   August 29, 2000; is that correct?
22   A    That's correct.
23   Q    Is that your one and only report?
24   A    Yes.
25   Q    And are your reports -- pardon me, are
0004
 1   your opinions contained entirely within that
 2   report?
 3   A    Insofar as -- as of the time that I
 4   wrote it based on the materials available to
 5   me at that time.  There, of course, may be
 6   other opinions in response to questions or
 7   in response to your questions today that I
 8   may hold in this case.
 9   Q    But do you have any new opinions since
10   -- since the time you authored that report
11   until today?
12   A    If you could define new opinions,
13   perhaps I could give them.
14   Q    Well, I guess, Doctor, to cut it short,
15   do you attend -- do you intend to offer an
16   opinion on survival; in other words, had
17   treatment been rendered earlier, whether her
18   chances of survival would have been higher?
19   A    Could you put that in the form of a
20   question?
21   Q    Okay.  Do you intend to offer an
22   opinion, or do you have an opinion on
23   whether, had treatment been rendered
24   earlier, this young lady would have had a
25   better prognosis?
0005
 1   A    Yes, I have an opinion.
 2   Q    Okay, and what is your opinion, Doctor?
 3   A    No, she would not have survived.
 4   Q    And the basis of that opinion, Doctor?
 5   A    She had a medical condition which
 6   carries a high mortality, and she didn't --
 7   and when it was diagnoseable, she could not
 8   have survived.
 9   Q    Well, when was it diagnoseable, Doctor?
10   A    I think it was diagnoseable some time
11   in the morning of the day of the 26th.
12   Q    Do you have an opinion, Doctor,
13   whether, had treatment been rendered, for
14   example, on the 25th, whether she would have
15   had a better chance of survival?
16             MR. JEFFERS:   Objection.  Go
17   ahead.
18             THE WITNESS:   She may have had a
19   better chance.
20   BY MR. JACOBSON:
21   Q    Okay.  All right.  We'll get into that
22   then later, Doctor.  Doctor, what is the
23   nature of your current practice?
24   A    I'm an obstetrician/gynecologist in
25   private practice in Lake County, Ohio.
0006
 1   Q    What hospitals, Doctor, do you have
 2   privileges at?
 3   A    The Lake County system which is Lake
 4   East and Lake West.
 5   Q    Okay, where do you deliver most of your
 6   babies at, Doctor?
 7   A    At the Lake East facility.
 8   Q    Okay.  How often do you get to Lake
 9   West?
10   A    Rarely.
11   Q    Okay.  Doctor, Lake East and Lake West,
12   are they community hospitals?
13   A    Yes, sir.
14   Q    Are they teaching facilities?
15   A    No, sir.
16   Q    Are there house officers, obstetrical
17   house officers in those hospitals?
18   A    Yes, sir.
19   Q    Okay.  Are they -- they're around the
20   clock?
21   A    Yes, sir.
22   Q    And the house officers are
23   obstetricians; is that correct?
24   A    Yes, sir.
25   Q    Doctor, you currently have no academic
0007
 1   appointment; is that correct?
 2   A    That's correct.
 3   Q    And when was the last time that you had
 4   an academic appointment?
 5   A    It would have been expired in 1998.
 6   Q    Okay, and that academic appointment was
 7   an associate professorship at Case Western,
 8   Doctor?
 9   A    That's correct.
10   Q    And why did you not renew that, or why
11   was that not renewed?
12   A    I left University Hospitals and Case
13   Western Reserve in '96, and for a variety
14   of, I think, administrative reasons, it
15   doesn't expire until '98, but I left there
16   in '96.
17   Q    Why did you leave, Doctor?
18   A    To pursue new career avenues.
19   Q    Okay.  Doctor, were your privileges
20   suspended or revoked for any reason?
21   A    No, sir.
22   Q    Were you asked to leave, Doctor?
23   A    No, sir.
24   Q    Doctor, when you were at -- when you
25   did have your academic appointment, did you
0008
 1   do any didactic lecturing, or was it just
 2   rounds primarily?
 3   A    I had a full range of teaching
 4   activities which included rounds, didactic
 5   lectures for a variety of medical students,
 6   residents, attending staff.
 7   Q    How often did you do didactic
 8   lecturing?
 9   A    Depending on the venue and the format,
10   at least once a week.
11   Q    When is the last time, Doctor, that you
12   submitted a peer review article for
13   publication?
14   A    Our last one appeared in -- I say "our"
15   because there's more than one author.  If I
16   can look at my CV.
17   Q    Please.
18   A    I think it was 19 -- 1998.
19   Q    Okay, and what was that article, Doctor?
20   A    That was "Indirect Prediction of Fetal
21   Lung Maturity, Value of Ultrasonic, Colonic
22   and Placental Grading."
23   Q    Doctor, would it be fair to say that,
24   since you have left Case, you've done no
25   research or submitted no articles; is that
0009
 1   correct?
 2   A    That's correct.
 3   Q    And, Doctor, the number of -- of peer
 4   reviewed articles that you have submitted
 5   for publication actually since -- since your
 6   fellowship has just been a few, correct?
 7   A    The number is there for you to see.
 8   Q    Okay.  Is it less than five, Doctor?
 9   A    No, I don't think so.
10   Q    Well, Doctor, are we counting the
11   letters to the editor, that sort of thing,
12   or the annual report?  We're not going to
13   count those as peer reviewed articles;
14   correct, Doctor?
15   A    That's correct.
16   Q    Doctor, you indicate that you are a
17   reviewer for the Journal of Perinatology and
18   Obstetrics & Gynecology, correct?
19   A    Yes.
20   Q    Have you ever held an editorship or
21   associate editorship on either of those
22   journals, Doctor?
23   A    No, sir.
24   Q    Any professional journal?
25   A    No, sir.
0010
 1   Q    How often are you asked to participate
 2   in the review of peer reviewed articles on
 3   those journals?
 4   A    On occasion.
 5   Q    Okay, in the last two years, how many
 6   times, Doctor?
 7   A    Once.
 8   Q    Are you still continuing on with that?
 9   A    I would do them if so asked.
10   Q    And -- but you've only been asked once
11   since you left Case?
12   A    Yes, sir.
13   Q    Do you know why that is?
14   A    No.
15   Q    Do you know of Dr. Gimovsky?
16   A    I have heard the name.
17   Q    Have you attended seminars where he's
18   lectured?
19   A    Not that I recall.
20   Q    Okay.  Is he an individual who is held
21   in extremely high regard by his peers?
22             MR. JEFFERS:   Extremely high
23   regard?  Go ahead.
24             THE WITNESS:   What does that
25   mean?
0011
 1   BY MR. JACOBSON:
 2   Q    As -- as you understand it in lay
 3   terms, Doctor, is he an individual who's
 4   held in extremely high regard by his peers?
 5   A    He's a physician that gives lectures.
 6   Q    Well, Doctor, with all due respect,
 7   though, that's not responsive to my
 8   question.  Is it your understanding that
 9   Doctor -- let's just start with high regard.
10   Is Dr. Gimovsky someone who's held in high
11   regard by his peers?
12   A    Could you define "high regard"?
13   Q    As you understand that term, Doctor.
14   A    Well --
15   Q    It's not a term of art, so --
16   A    In terms of doctors, I'm not sure I
17   know what "high regard" means.
18   Q    Uh-huh.  Okay, well, is it your
19   testimony, Doctor, that you don't know what
20   "high regard" means?  Then we'll move on.
21             MR. JEFFERS:   No, that's not
22   fair.  You're asking him how -- whether he's
23   held in high regard.  It doesn't -- maybe he
24   doesn't know what regard this particular
25   doctor is held in.
0012
 1             MR. JACOBSON:   That wasn't his
 2   answer, John.
 3             MR. JEFFERS:   It was.
 4             MR. JACOBSON:   His answer is he
 5   doesn't know what it means.
 6             MR. JEFFERS:   Because you gave a
 7   rather flip response -- question or
 8   statement at the end of that, which I don't
 9   think is appropriate.  Now, you can ask him
10   the question.  You don't need editorials.
11   BY MR. JACOBSON:
12   Q    Do you know of Dr. Martens?
13   A    I've heard the name.
14   Q    Have you attended lectures that he has
15   given?
16   A    Not that I recall.
17   Q    Have you read literature that has been
18   published by Dr. Gimovsky or Dr. Martens
19   from time to time?
20   A    Yes.
21   Q    Okay.  What professional journals,
22   Doctor, do you receive in your practice?
23   A    The Journal of Obstetrics &
24   Gynecology, commonly referred to as the
25   Green Journal; the American Journal of
0013
 1   Obstetrics & Gynecology, commonly referred
 2   to as the Gray Journal; the Journal of
 3   Reproductive Medicine are the ones -- are
 4   the ones I receive.
 5   Q    Gimovsky and Martens are frequent
 6   contributors to those journals, correct?
 7   A    I'm not sure I know what you mean by
 8   "frequent."  They have published in those
 9   journals, yes.
10   Q    Do you know Dr. -- did you know whether
11   Dr. Gimovsky is an editor or associate
12   editor of any of those journals?
13   A    I don't know at this time.
14   Q    Doctor, you have never written an
15   article on the topic at hand, i.e. the
16   diagnosis and treatment of infection,
17   correct?
18   A    That's correct.
19   Q    Doctor, have you ever been elected or
20   served as an officer of any professional
21   organization within your specialty?
22   A    Of a national organization?
23   Q    No, at any level, Doctor, national,
24   regional or local.
25   A    The local level, yes, sir.
0014
 1   Q    Okay, and what is that?
 2   A    I sat on the board of the Cleveland
 3   OB/GYN Society.
 4   Q    When was that?
 5   A    I'm not sure.  It's in my CV.  It was
 6   back in the '80's.
 7   Q    In the last 15 years, Doctor, have you
 8   been elected or served as an officer of any
 9   professional organization with respect --
10   within your specialty?
11   A    Other than the one I just mentioned,
12   no.
13   Q    Have you ever served as a house officer?
14   A    Yes, sir.
15   Q    When was that?
16   A    I do currently.
17   Q    Okay.  How frequently is that?
18   A    Every fifth night.
19   Q    Okay.  Doctor, have you ever taught
20   obstetrical nurses?
21   A    Yes, sir.
22   Q    And when is that?
23   A    Every month or so.
24   Q    Under what circumstances?
25   A    I give lectures.
0015
 1   Q    Have you ever taught obstetrical nurses
 2   on the topic of the diagnosis and treatment
 3   -- treatment of infection or recognition of
 4   infection?
 5   A    Not that I recall.
 6   Q    Have you ever been involved, Doctor, in
 7   authoring protocols for obstetrical nurses
 8   or hospitals?
 9   A    I have certainly assisted in many
10   hospitals in authoring what I would call
11   guidelines for professional practice.
12   Q    When was the last time that you did
13   that, something like that, Doctor?
14   A    A couple of weeks ago.
15   Q    Do you know Dr. Hsieh or Dr. Hahn?
16   A    I know Dr. Hahn.
17   Q    Okay, and how do you know Dr. Hahn?
18   A    He was a resident at University
19   Hospitals when I was on the faculty there.
20   Q    Was he a student of yours, then?
21   A    He was a resident.  I was on the
22   faculty.
23   Q    Do you have any personal relationship
24   with Dr. Hahn?
25   A    I haven't spoken to him in probably
0016
 1   four or five years.
 2   Q    Doctor, the hospitals that you
 3   currently have privileges at, the two
 4   community hospitals, Lake East and Lake
 5   West, do they have written chain of command
 6   protocols?
 7   A    Not that I'm aware.
 8   Q    Certainly, University Hospitals did,
 9   correct?
10   A    I was never aware of it.
11   Q    How many years were you at University
12   Hospitals?
13   A    Eighteen on the attending staff.
14   Q    And as we sit here today, you're
15   unaware as to whether University Hospitals
16   had written chain of command protocols,
17   correct?
18   A    That is correct; I'm unaware.
19   Q    Doctor, are you familiar with AWON and
20   its predecessor, NAACOG?
21   A    Yes, sir.
22   Q    The AWON materials make a statement
23   that obstetrical nurses have the duty to
24   exercise their independent judgment in the
25   care and treatment of their patients.  Have
0017
 1   you heard that statement, Doctor?
 2   A    If you say that's where that's from,
 3   that's fine.
 4   Q    Have -- have you heard that statement,
 5   or have you read that statement in -- in the
 6   literature?
 7   A    I may have.
 8   Q    Okay.  It sounds somewhat familiar?
 9   A    It could.
10   Q    Doctor, is that a statement that you
11   agree with?
12   A    In the broadest terms, sure.
13   Q    What is your understanding of the term,
14   independent judgment?  What does that mean?
15   A    Independence when making a decision or
16   initiating an action based on their own
17   assessment.
18   Q    Doctor, if a nurse, an obstetrical
19   nurse, of course, in the exercise of her
20   independent judgment feels that a patient is
21   not receiving appropriate care, does the
22   nurse have the duty to speak out on behalf
23   of her patient?
24   A    Is this a hypothetical question?
25   Q    Yes.
0018
 1   A    Because this has no relevance in this
 2   particular case, so hypothetically, yes.
 3   Q    Okay.  Doctor, that duty exists whether
 4   there's a written chain of command or not,
 5   correct?
 6   A    It can.
 7   Q    It -- my question to you is, Doctor:
 8   every single hospital where there's an
 9   obstetrical unit, if a nurse, in this -- in
10   this country, if the nurse by the exercise
11   of her independent judgment feels the
12   patient is not receiving appropriate care,
13   does that nurse have a duty to speak out on
14   behalf of her patient?  Is that true in
15   every hospital in this country?
16   A    I don't know that.
17   Q    Okay.  Well, Doctor, do you feel that
18   that is the appropriate standard of care for
19   obstetrical nurses?
20   A    It can be, yes.
21   Q    Well, indeed, Doctor, it is, correct?
22   A    As a hypothetical, yes.
23   Q    Okay.  Doctor, you're here on behalf of
24   Parma Hospital and are holding yourself out
25   as an expert in the standard of care for
0019
 1   obstetrical nurses, correct?
 2   A    Yes.
 3   Q    Okay.  Does Parma Hospital have a -- a
 4   nursing expert in this case?
 5             MR. JEFFERS:   Objection.  He is.
 6   BY MR. JACOBSON:
 7   Q    Okay.  Well, do they have -- pardon.  I
 8   stand corrected then.  I think Mr. Jeffers
 9   --
10             Doctor, I guess what I meant to
11   say was:  has Parma Hospital offered the
12   expert testimony of a nurse on behalf of the
13   nurses?
14   A    Not that I'm aware of.
15   Q    Okay.  Have you ever suggested to Parma
16   Hospital or Mr. Jeffers that they, indeed,
17   should have a nursing expert?
18   A    No, sir, I've not offered that opinion.
19   Q    Let's get back to the nurse's duty to
20   speak out on behalf of her patient, and
21   we've already agreed, Doctor, that that duty
22   exists whether there's a written chain of
23   command or not, correct?
24   A    Yes.
25   Q    In other words, Doctor, in a sense,
0020
 1   there is always a chain of command in place,
 2   whether it's written or not, correct?
 3   A    Yes, sir.
 4   Q    Now, Doctor, the chain of command
 5   begins with the nurse speaking to the
 6   physician to express her dissatisfaction,
 7   correct?
 8   A    It can on some occasions.
 9   Q    Well, in other words, Doctor, before
10   the -- before the -- the nurse would go to
11   her charge nurse or -- or over the
12   physician's head, the prudent nurse will
13   speak to the physician to express her
14   dissatisfaction with the patient's care,
15   correct?
16   A    I'm not sure I would use the term
17   "dissatisfaction."
18   Q    Well, let's assume -- let's assume that
19   -- let's assume that the nurse is
20   dissatisfied or concerned.
21   A    "Concerned" is a better word.
22   Q    Okay.  The prudent nurse will begin
23   with speaking to the physician about the
24   patient, correct?
25   A    Yes.
0021
 1   Q    All right.  Now, that communication is
 2   different than simply a status update where
 3   you call the doctor and say:  these are the
 4   labs; these are the vitals; this is the
 5   patient's clinical condition, correct?
 6   A    Not necessarily.
 7   Q    Well, that's my question, Doctor.  If a
 8   nurse is dissatisfied or concerned about the
 9   patient and the course of the patient's
10   care, does that nurse have a duty to go
11   beyond simply reporting to the doctor the
12   status of the patient and say to the doctor:
13   I'm concerned, or will you come in, or
14   something of that nature?
15             MR. JEFFERS:   Would you read that
16   question back?
17             (At this time the previous
18   question was read back.)
19             MR. JEFFERS:   I object to that
20   question.  I think there's two different
21   words used, two different connotations.
22   BY MR. JACOBSON:
23   Q    Let me rephrase it.  I want to ask you
24   to assume that at approximately 12:45 a.m.
25   on the 26th, that Nurse Prokop did not feel
0022
 1   that the care that was being rendered to
 2   this patient was adequate.
 3             MR. KADLEC:     Objection to the
 4   question as it's asked.
 5   BY MR. JACOBSON:
 6   Q    Assuming that to be true, did Nurse
 7   Prokop discharge her duty to this patient by
 8   calling Dr. Hahn and reporting on the
 9   patient's condition without taking the next
10   step and expressing those concerns?
11             MR. JEFFERS:   Objection.
12             MR. KADLEC:    Join.
13             THE WITNESS:   May I look at my
14   records for a second?
15   BY MR. JACOBSON:
16   Q    Please.
17             MR. JACOBSON:  John, can you hand
18   him those
19             MR. KADLEC:    Read that one
20   back.
21             (At this time the previous
22   question was read back.)
23             THE WITNESS:   That's too
24   difficult a question to answer simply.  We
25   are talking about what time now?
0023
 1             MR. JEFFERS:   0045.
 2             THE WITNESS;   On what date?
 3             MR. JEFFERS:   The 26th.
 4             THE WITNESS:   And now the
 5   question is?
 6             (At this time the previous
 7   question was read back.)
 8             MR. JEFFERS:   And there was a
 9   prefix question to that.  So it's
10   disjunctive, so that's -- I think if you can
11   answer it, answer it.
12             THE WITNESS:   Well, I'm not sure
13   I can because it started with assuming that
14   to be true or something to be true first,
15   which is a hypothetical.
16   BY MR. JACOBSON:
17   Q    Well, let me just take this out of the
18   context of this case and put it in terms of
19   a hypothetical in general, Doctor, okay?  If
20   a nurse is concerned that -- that -- about
21   her patient and is concerned that the
22   patient's course of care is inappropriate,
23   does the nurse satisfy her duty to her
24   patient by calling the doctor and reporting
25   on the patient's condition, vitals, labs?
0024
 1   Does that in and of itself satisfy the
 2   nurse's duty to her patient when she says
 3   that and nothing more?
 4   A    It can.
 5   Q    In other words, Doctor, I'm going to
 6   ask you this in front of a jury too, and I
 7   want to make sure I've got -- I want to make
 8   sure I understand your opinion here.  If a
 9   nurse thinks that the doctor is not doing
10   what he should, does she satisfy her duty to
11   the patient by simply calling the doctor and
12   reporting to the doctor on the patient's
13   status?
14             MR. JEFFERS:   That's a different
15   question.  Go ahead.
16             THE WITNESS:   She can, yes.
17   BY MR. JACOBSON:
18   Q    In other words, Doctor, that -- that
19   does satisfy the nurse's duty?  She's now
20   discharged her obligation to this patient?
21   A    It can.
22   Q    Okay.  When you say "it can," I don't
23   understand what you mean by that.
24   A    It can satisfy her obligation to the
25   patient.
0025
 1   Q    Well, let's -- let's further assume in
 2   the hypothetical that the doctor does not
 3   change the course of treatment.
 4   A    Yes.
 5   Q    So, the nurse is now -- in spite of the
 6   fact that the nurse has -- has reported the
 7   patient's status to the physician, and is
 8   still concerned that the doctor's not doing
 9   the right thing, the doctor doesn't change
10   anything.  Has the nurse -- but the nurse
11   has not in my hypothetical, Doctor, told the
12   doctor about her concern or her worry that
13   the patient's not getting correct care.  Has
14   she discharged her duty to this patient?
15             MR. KADLEC:    Objection.
16             MR. JEFFERS:   I'll object.  Go
17   ahead.
18             THE WITNESS:   Yes.
19   BY MR. JACOBSON:
20   Q    Okay.  Well, I think maybe, Doctor, the
21   better way to go after this is to just have
22   you explain to me the extent of the nurse's
23   duty to the patient who she doesn't feel is
24   getting cared for appropriately, and when
25   that duty is discharged, if you would.
0026
 1   A    I'm not sure I can answer that
 2   question.
 3   Q    Well, the nurse has a patient.  She
 4   doesn't think the doctor is doing the right
 5   thing.
 6   A    Then, she --
 7   Q    What's her duty, and when does she
 8   discharge that duty?
 9   A    She notifies the physician.
10   Q    Okay.  The physician doesn't do
11   anything.  Now, wait.  When you say she
12   notifies the physician, let's say she calls
13   the physician and reports on the patient's
14   status.
15   A    Yes.
16   Q    The physician doesn't change anything.
17   Has she discharged her duty to -- to that
18   patient?
19   A    Yes.
20   Q    Okay.  So, you don't think, then, that
21   a nurse has a duty to -- to take the next
22   step and tell the doctor that she doesn't
23   think he's doing the right things?
24   A    No, that can happen.
25   Q    And what -- what are the variables,
0027
 1   Doctor?
 2   A    The patient's status.
 3   Q    Well, Doctor, in our hypothetical
 4   patient, the nurse is concerned about the
 5   patient's condition.  The patient -- the
 6   nurse is concerned that the patient is
 7   deteriorating.  That's the status.
 8   A    Then, she can pursue it, and -- through
 9   the chain of command.
10   Q    Well, the chain of command begins with
11   speaking to the physician, correct?
12   A    Correct.
13   Q    All right.  Now, when the nurse is
14   concerned that the patient is deteriorating,
15   and the nurse feels that the doctor is not
16   doing the right things for the patient, does
17   the nurse discharge her duty to the doctor
18   by simply calling and giving a status
19   report, or need the nurse do more than that?
20             MR. JEFFERS:   This is a different
21   question now, because he's using different
22   terms.
23             THE WITNESS:   This is a different
24   question because you just changed the word.
25             MR. JACOBSON:  All right.  Can we
0028
 1   read that back?
 2             MR. JEFFERS:   Yeah, you said
 3   "deteriorating."
 4             MR. JACOBSON:  Okay.
 5             (At this time the question was
 6   read back.)
 7             MR. KADLEC:    I'll object.
 8   BY MR. JACOBSON:
 9   Q    Your answer, Doctor?
10             MR. JEFFERS:   Object.  Go ahead.
11             THE WITNESS:   Yes, she discharges
12   her responsibility to the doctor.
13   BY MR. JACOBSON:
14   Q    How about her responsibility to the
15   patient?
16   A    That's a different question.
17   Q    Okay.
18   A    The question is?
19             (At this time the question was
20   read back.)
21   BY MR. JACOBSON:
22   Q    Pardon me.  I meant discharge her duty
23   to the patient.
24   A    That is not what you said.
25   Q    Okay.  I apologize.  Now, let me just
0029
 1   restate the question again.
 2   A    Please.
 3   Q    The nurse feels the patient's status is
 4   deteriorating.  The nurse feels the doctor
 5   is not doing the right things.  Does the
 6   nurse discharge her duty to the patient by
 7   simply calling the doctor and reporting on
 8   the status?
 9   A    She may or may not.
10   Q    Okay, and let's assume that the doctor
11   doesn't change anything.  Has the nurse
12   discharged her duty?
13   A    She may or may not have.
14   Q    And what are the variables, Doctor?
15   A    The status of the patient.
16   Q    Well, the nurse thinks the patient is
17   deteriorating.  That's the patient's status.
18   A    It depends on the level of
19   deterioration, what the threat to the
20   patient's health is, variables such as that.
21   Q    Okay.  So, the variable is the level of
22   concern, really, that the nurse has for the
23   patient.  That's the variable.
24   A    One of them.
25   Q    That's the main one, correct?
0030
 1   A    It's one of them.
 2   Q    If the nurse is very worried about the
 3   patient, and if she feels that the patient's
 4   status is deteriorating, and she feels that
 5   the doctor's not treating the patient
 6   correctly, and she calls the doctor to
 7   report on the patient's status, and the
 8   doctor doesn't do anything, then, under
 9   those circumstances, the nurse needs to tell
10   the doctor:  doctor, I think, or -- or tell
11   the doctor of her concerns; is that a fair
12   statement?
13   A    As a hypothetical, yes.
14   Q    Okay.  In that hypothetical, simply
15   reporting on the status and acquiescing in
16   the doctor's not changing the course of
17   care, in that hypothetical, that's
18   inadequate, correct?
19   A    In that hypothetical, it might be
20   considered inadequate.
21   Q    You would think it would be inadequate,
22   correct, Doctor?
23   A    It -- it may be, but there's a lot of
24   variables in this particular scenario.
25   Q    Doctor, in your review of this record,
0031
 1   did any nurse between 7:30 p.m. on the 25th
 2   and 7:30 a.m. on the 26th, in that 12-hour
 3   period, express her dissatisfaction or
 4   concern about this patient to Dr. Hahn?
 5   A    I think Dr. Hahn was called a number of
 6   times, and various aspects of this patient's
 7   condition and care were discussed.
 8   Q    Okay.  Well, we certainly know that Dr.
 9   Hahn was called.
10   A    Yes.
11   Q    And the patient's status was reported
12   to Dr. Hahn, correct?
13   A    Yes.
14   Q    All right.  Now, did any nurse take the
15   next step and go beyond reporting the status
16   and express her concerns or dissatisfaction
17   to Dr. Hahn?
18             MR. JEFFERS:   Objection.
19             MR. KADLEC:    Object.
20             MR. JEFFERS:   There's two
21   different things, concerns and
22   dissatisfaction because --
23             MR. JACOBSON:   Okay.  I'll take
24   them one at a time, okay.
25             MR. JEFFERS:   -- it's obvious she
0032
 1   did discuss concerns in the reporting of it.
 2   BY MR. JACOBSON:
 3   Q    Did any -- did any nurse express her
 4   dissatisfaction to Dr. Hahn with the course
 5   of care?
 6   A    Obviously, that's how care is done.
 7   Q    In other words, you -- is it your
 8   opinion, Doctor, that implicit in the call
 9   was her dissatisfaction?
10   A    Absolutely.
11   Q    Okay.
12             MR. KADLEC:    Objection.  Bill,
13   so I don't have to keep objecting, can I
14   have a continuing objection to any time you
15   use the phrase the nurse is dissatisfied
16   with the doctor's care as hearsay?
17             MR. JACOBSON:   Sure.
18   BY MR. JACOBSON:
19   Q    Well, let's explore that.  Do you feel
20   that Dr. Hahn, by the sheer number of calls
21   and the fact that they came in the middle of
22   the night, should have been aware of the
23   nurse's dissatisfaction with the care that
24   Dr. Hahn was giving this patient?
25             MR. JEFFERS:   Objection.  That's
0033
 1   --
 2             MR. KADLEC:    Objection
 3             MR. JEFFERS:   -- an entirely
 4   different question than you just asked.
 5             MR. JACOBSON:   Well, it is a
 6   different question.
 7             MR. KADLEC:    Did you get my
 8   objection?
 9             MR. JEFFERS:   Well, it makes you
10   -- you stated it, making it almost sound
11   like it's -- it's a -- it follows from the
12   last question, which it doesn't.  Okay.  So,
13   we understand it's an entirely new subject
14   now.
15             MR. JACOBSON:  Well, wait.  I'm
16   confused, John.
17   BY MR. JACOBSON:
18   Q    In other words, Dr. Duchon, I don't
19   want to put words in your mouth.  It's your
20   -- it's your thought and you've testified
21   that by the number of calls and the timing
22   of the calls, implicit in -- in that fact is
23   the nurse's dissatisfaction, correct?
24             MR. JEFFERS:   With the status, he
25   said.
0034
 1             MR. JACOBSON:   Pardon?
 2             MR. JEFFERS:   With the status.
 3   The word he used was "status."  You're
 4   forgetting what he said.
 5             MR. JACOBSON:   Well, dissatisfied
 6   with the status, okay.  All right.
 7   BY MR. JACOBSON:
 8   Q    Do you feel that -- that -- that the
 9   calls that were made by the nurses between
10   7:30 p.m. and 7:30 a.m. or by Dr. Hsieh were
11   sufficient to express their dissatisfaction
12   with the course of care to Dr. Hahn?
13   A    I don't think they were communicating
14   dissatisfaction with the course of care.  I
15   think they were communicating their concerns
16   over the patient's status.
17   Q    Okay.  So, in your opinion, Doctor,
18   there was no nurse that communicated her
19   dissatisfaction with the course of care to
20   Dr. Hahn in that period, correct?
21   A    I think there was the clinical
22   interaction between the doctors and the
23   nurses discussing the patient's status and
24   condition and the evolution of it.
25   Q    Once again, Doctor, did any nurse in
0035
 1   that 12-hour period, 7:30 p.m. on the 25th
 2   to 7:30 a.m. on the 26th, express any
 3   dissatisfaction to Dr. Hahn with his -- with
 4   the course of care, either explicitly or
 5   implicitly?
 6   A    As I stated, implicit in phone calls is
 7   a certain, shall we say, concern or
 8   dissatisfaction, using your word.
 9   Q    Okay.  With the course of care, though,
10   as opposed to the patient's condition.  I'm
11   looking for the course of care.
12   A    And what does that mean?
13   Q    The way that Dr. Hahn was handling this
14   patient, his orders.
15   A    And what is the question?
16   Q    The question is that, between 7:30 p.m.
17   on the 25th and 7:30 a.m. on the 26th, did
18   any nurse express her dissatisfaction with
19   the course of care that Dr. Hahn was
20   rendering to this patient?
21   A    Not that I'm aware of at this time.
22   Q    Okay.  So, there's no way that Dr. Hahn
23   would have known -- strike -- strike that.
24   Assuming hypothetically that the nurses did
25   not think the course of care was
0036
 1   appropriate, there's no way that Dr. Hahn
 2   would have known that in that time frame,
 3   correct?
 4             MR. JEFFERS:   Objection.  It
 5   doesn't follow at all.
 6             MR. JACOBSON:   I disagree with
 7   that, John.  Can you read back the question?
 8             (At this time the question was
 9   read back.)
10             THE WITNESS:   I'm not sure I
11   understand that question.
12   BY MR. JACOBSON:
13   Q    Well, if these nurses -- if the nurses
14   that were caring for Mrs. Williams didn't
15   think that Dr. Hahn was doing the right
16   thing, they certainly did not relay that to
17   Dr. Hahn, according to the record and the
18   deposition testimony, correct?
19   A    That's correct.
20   Q    Okay.  Have you heard the phrase or
21   read the phrase that the nurse is the eyes
22   and ears of the doctor?
23   A    No, not really.
24   Q    You never heard that one?
25   A    Never heard that one.
0037
 1   Q    Okay.  The doctor, particularly a
 2   doctor who's not in attendance physically at
 3   the hospital, must rely heavily on the
 4   nurses, correct?
 5   A    They rely on the nurses.
 6   Q    And they rely on the nurse -- nurses to
 7   give them complete and accurate information,
 8   correct?
 9   A    That's what's sought.
10   Q    And they rely on the nurse to that
11   effect, correct, Doctor?
12   A    At times, yes.
13   Q    Well, when they're not there, they're
14   entirely relying on the nurse, correct, to
15   tell them what's going on with their patient?
16   A    If something's going on, yes.
17   Q    All right.  All right, let's -- let's
18   turn then, Dr. Duchon, to certain signs and
19   symptoms and -- and lab values, and I -- and
20   I want to get your understanding as to what
21   your expectation would be of a registered
22   nurse's knowledge in this regard, okay?
23   Doctor, would you expect a registered nurse
24   to understand the elevation of the white
25   blood count as a potential sign of
0038
 1   infection?
 2   A    Possibly.
 3   Q    Well, Doctor, when you say "possibly,"
 4   the nurses that you work with, do you expect
 5   them in every patient to recognize that --
 6   that the elevation of the white blood count
 7   is a potential sign of infection?
 8   A    No.
 9   Q    Okay.  Maybe I didn't phrase that
10   right.  You would expect every nurse that
11   you work with in general to understand that
12   there's an association between infection and
13   elevation of white blood count?
14   A    No, I don't expect that.
15   Q    Is it your understanding that -- that
16   registered nurses are taught that, when
17   there is an infection, the white blood count
18   will tend to rise?
19   A    They are taught that.  I don't expect
20   them to make a judgment, though, about it.
21   Q    Okay.  You expect them to know that but
22   not make a judgment, fair enough?
23   A    In certain circumstances.
24   Q    Okay.  Do you expect registered nurses
25   to be taught that the production of immature
0039
 1   white blood cells will occur with infection?
 2   A    Nope.
 3   Q    So, you expect a registered nurse to
 4   understand the elevation of a white blood
 5   count and the significance of that, but not
 6   a left shift, correct?
 7             MR. JEFFERS:   Not what?
 8   BY MR. JACOBSON:
 9   Q    A left shift or bandemia, correct?
10             MR. JEFFERS:   Those are two
11   questions.
12             THE WITNESS:   That was two
13   questions.
14   BY MR. JACOBSON:
15   Q    All right.  Do you expect -- do you --
16   do you expect a registered nurse to
17   understand that, when there's an infectious
18   process, you can have a left shift?
19   A    No, not necessarily.
20   Q    Okay, and do you expect a registered
21   nurse, Doctor, to understand that, when
22   there's bandem -- pardon me, that, when
23   there's an infection, you can have bandemia?
24   A    No.
25   Q    Okay.  So, those things may be beyond
0040
 1   -- may be beyond the scope of a reasonable
 2   nurse, correct?
 3   A    Correct.
 4   Q    Who is the director of nursing at Lake
 5   East, Doctor?
 6   A    The director of nursing services at
 7   Lake Hospital Systems is -- Delane Vencl is
 8   her name.
 9   Q    Can you spell that, please?
10   A    V-E-N-C-L is her last name.
11   Q    And she's the director of nursing for
12   both Lake East and Lake West, correct?
13   A    As far as I understand, yes.
14   Q    Okay.  Do you know what her background
15   is, Doctor?
16   A    She went to nursing school with my
17   wife.
18   Q    Has she had any training as an
19   obstetrical nurse?
20   A    They -- obviously my wife and she had
21   different careers through -- through
22   medicine, but that's how I know her.
23   Q    She was an obstetrical nurse?
24   A    No.  She was, I think, primarily a
25   med/surg nurse.
0041
 1   Q    Now, if we were to subpoena her as a
 2   rebuttal witness, and she were to testify
 3   that she expects the nurses under her charge
 4   to understand the association between a left
 5   shift and infection or bandemia and
 6   infection, would you defer to her in that
 7   regard, Doctor?
 8             MR. JEFFERS:   Objection.  This is
 9   argumentative now, and if you want to
10   respond, you may.
11             THE WITNESS:   You asked me what I
12   expected from the nurses, and that is what I
13   told -- answered to.
14   BY MR. JACOBSON:
15   Q    All right.  Well, let me rephrase it.
16   Do you expect a registered nurse to know of
17   a potential association between bandemia and
18   infection?
19   A    Many nurses may know of such an
20   association.
21   Q    Do you -- Doctor, is it your opinion
22   that a registered nurse caring for an
23   obstetrical patient should know of a
24   potential association between bandemia and
25   infection?
0042
 1   A    No, sir.
 2   Q    Okay.
 3   A    She should not know that that.
 4   Q    Okay.  Do you expect a registered nurse
 5   to know what bandemia is?
 6   A    No, sir, I do not expect that.
 7   Q    Okay.  Do you expect a registered
 8   nurse, Doctor, to know what a left shift is?
 9   A    No, sir, I do not expect that.
10             MR. JEFFERS:   You -- you have
11   now repeated those questions.  You went
12   through those before about two and a half
13   minutes ago.
14   BY MR. JACOBSON:
15   Q    And if Ms. Vencl indicates that she
16   feels that a registered nurse should indeed
17   know those things, would you defer to her in
18   that regard?
19             MR. JEFFERS:   Objection.  This is
20   argumentative again.  Go ahead and answer,
21   if you can.
22             THE WITNESS:   You've asked for my
23   opinion.
24   BY MR. JACOBSON:
25   Q    Uh-huh.
0043
 1   A    What --
 2   Q    And I'm asking you if you would defer
 3   your opinion to Ms. Vencl.
 4             MR. JEFFERS:   Objection.
 5   BY MR. JACOBSON:
 6   Q    To that of Ms. Vencl.
 7   A    In terms of what nurses should know?
 8   Q    Yes.
 9   A    She will have her opinion.
10   Q    Doctor, are you aware from the chart --
11   pardon me.  Are you aware from the
12   depositions as to whether Nurse Prokop knew
13   what bandemia was or a left shift was?
14   A    Can I look for a second?
15             MR. JEFFERS:   Dave, do you want
16   to point out what page that might be on?
17             MR. PARIS:     Eighteen.
18             MR. JEFFERS:   Pardon me?
19             MR. PARIS:     Eighteen, 19, 20.
20   Nurse Prokop, right?
21             MR. JEFFERS:   Yes.
22             THE WITNESS:   Now, what is the
23   question?
24   BY MR. JACOBSON:
25   Q    Doctor, are you aware whether the
0044
 1   nurses caring for this patient were aware of
 2   an association between bandemia and
 3   infection or a left shift and infection?
 4             MR. JEFFERS:   Your question
 5   originally was Prokop.  Are you now --
 6             MR. JACOBSON:   All right, Nurse
 7   Prokop.  Let's begin with her.
 8   BY MR. JACOBSON:
 9   Q    Was she aware of such an association,
10   Doctor?
11   A    She has a vague understanding of an
12   association, yes.
13   Q    What about the other nurses, Doctor?
14             Well, Doctor, before you look in
15   the deposition, my question is --
16   A    Yes.
17   Q    -- as we sit here:  do you know whether
18   the other nurses had that understanding
19   without referring to the records?
20   A    I think they all had -- had an
21   understanding that there is an association
22   between a white blood cell count and an
23   infection.
24   Q    And left shift as well, correct?  Did
25   they know -- do you know whether they knew
0045
 1   that?
 2   A    They said they -- they had some
 3   understanding.
 4   Q    All right.  Let's move on, Doctor.
 5   Shaking and shivering is a nonspecific
 6   symptom, but is consistent with infection,
 7   amongst others, correct?
 8             MR. JEFFERS:   Objection.  I think
 9   that's two.  That's a statement and a
10   question.  I'm not sure that -- go ahead, if
11   you can answer it.
12             MR. KADLEC:    Yes, objection.
13             MR. JEFFERS:   It's not well put,
14   as far as I can see the question.  So, I
15   don't want to have some confusion on there.
16   BY MR. JACOBSON:
17   Q    Shaking, Doctor, is a nonspecific
18   symptom but is consistent with infection,
19   correct?  All right, let me rephrase it.
20   Shaking, Doctor, is a nonspecific symptom
21   that can indeed be a symptom of infection,
22   correct?
23   A    No, I don't think I would accept that.
24   Q    Why is that?
25   A    I don't know what "shaking" means.
0046
 1   Q    Well, there's a term, Doctor,
 2   "shaking," in the record, okay?
 3   A    Yes, sir.
 4   Q    As you understand that term to be used
 5   as a lay term, Doctor --
 6   A    Yes.
 7   Q    -- as opposed to a term of art --
 8   A    Yes.
 9   Q    -- a patient who is shaking -- strike
10   that, Doctor.  Shaking, once again, is
11   nonspecific but can indeed be a symptom of
12   infection, correct?
13             MR. JEFFERS:   Objection.
14             THE WITNESS:   No, sir.
15   BY MR. JACOBSON:
16   Q    And why is that?
17   A    We use specific medical terms as
18   "chills" usually to reflect signs of
19   infection.
20   Q    So, you're differentiating between
21   "chills" and "shaking," correct?
22   A    Yes, sir.
23   Q    How about shivering, Doctor?  Is
24   shivering, Doctor, a potential sign of
25   infection?
0047
 1   A    It might be.
 2   Q    Okay.  Would you expect a nurse to know
 3   that?
 4   A    The usual medical term, as I said, is
 5   "chills."
 6   Q    Would you expect, Doctor, a nurse who
 7   notes shaking and shivering in a patient to
 8   -- to recognize that as a potential sign of
 9   infection?
10   A    She may or may not.
11   Q    And -- and -- but you would not have
12   that expectation then, correct?  In other
13   words, if the nurse didn't know that, you --
14   you -- you wouldn't have any criticism of
15   her degree of knowledge, correct?
16   A    Concerning shaking, that's correct.
17   Q    Shivering?
18   A    No.
19   Q    A nurse need not know that shivering is
20   a sign -- a potential sign of infection,
21   correct?
22   A    Chills, the nurse should know.
23   Q    All right.  All right, Doctor, what
24   about a patient who is generally not feeling
25   well, has a malaise; a nonspecific symptom,
0048
 1   but can be a sign of infection, correct?
 2   A    Could you restate that, please?   These
 3   are taking --
 4   Q    Malaise.
 5   A    Yes, sir.
 6   Q    All right, nonspecific?
 7   A    Quite.
 8   Q    Okay.  Can be a symptom of infection or
 9   a sign of infection?
10             MR. JEFFERS:   Objection because
11   the way these questions are all being asked
12   is on the equaling:  is it possible?  I
13   think they're inappropriate questions
14   because you're putting them in a possible,
15   total possible frame, and that's the reason
16   for my objection.  Go ahead.
17   BY MR. JACOBSON:
18   Q    Doctor, malaise can be a symptom of
19   infection, correct?
20   A    As you said, it's quite nonspecific.
21   Q    Doctor, but, indeed, is a sign or
22   symptom of infection, correct?
23   A    As much as anything else is, yes.
24   Q    All right.  A patient who is tired,
25   Doctor, that is nonspecific but can be a
0049
 1   sign of infection, correct?
 2             MR. JEFFERS:   Object, go ahead.
 3   I'll just object to --
 4             MR. JACOBSON:   Fine
 5             MR. JEFFERS:   -- the phrasing and
 6   form, and then I will then be quiet.  May I
 7   have that objection?
 8             MR. JACOBSON:   Doctor --
 9             MR. JEFFERS:   Wait.  Do you
10   agree?
11             MR. JACOBSON:   Yes, please.
12             MR. JEFFERS:   Thank you.
13   BY MR. JACOBSON:
14   Q    Tired, nonspecific, a potential sign of
15   infection, correct?
16   A    As much as anything else.
17   Q    Okay.  A patient who is groggy, Doctor,
18   nonspecific but a potential sign of
19   infection, correct?
20   A    As much as anything else.
21   Q    Okay, blurry vision, Doctor,
22   nonspecific, potential sign of infection,
23   correct?
24   A    Yeah, as a hypothetical for all of
25   these having nothing to do with this case,
0050
 1   sure.
 2   Q    Okay.  Now, certainly, Doctor, a nurse
 3   as well as a physician should realize that
 4   malaise, tiredness, grogginess, blurry
 5   vision are nonspecific but can be a sign of
 6   infection, correct?
 7   A    As a hypothetical, as I said, having
 8   nothing to do with this particular case,
 9   yes.
10   Q    Okay. All right, Doctor, a temperature
11   elevation of 101.6 in the puerperal period.
12   A    Yes.
13   Q    Is that, Doctor, potentially a sign of
14   infection?
15   A    No.
16   Q    Okay, and why is that?
17   A    Because in the first 24 hours they can
18   be perfectly normal.
19   Q    Once again, Doctor, my question to you
20   is:  is that a potential sign of infection?
21   A    As I said, no.
22   Q    So, you wouldn't concern yourself at
23   all and would not consider that to be
24   probative of infection, a temperature of
25   101.6 in the puerperal period, correct?
0051
 1   A    That is correct.
 2   Q    What is your definition of infection in
 3   the puerperal period?
 4   A    Huh?
 5   Q    Do you have a definition for infection
 6   -- pardon me, a definition of fever in the
 7   puerperal period?
 8   A    Over 102.
 9   Q    Uh-huh.
10   A    On a number of occasions.
11   Q    And from what source do you derive
12   that, Doctor?
13   A    That's my definition.  You asked for
14   it.
15   Q    Is there any text or article that you
16   can quote, Doctor?
17   A    You asked for my definition.
18   Q    Okay.  Well, I mean, I just want to
19   know if you derive that from anything that I
20   can look at.
21   A    No.
22   Q    Okay.
23   A    That's what I'm giving you.
24   Q    In general, Doctor, a temperature
25   elevation can be a sign of infection,
0052
 1   correct?
 2   A    In general, yes, sir.
 3   Q    Okay, and you would expect a nurse to
 4   know that as well, correct?
 5   A    I would expect a nurse to know the
 6   temperature elevation, yes.
 7   Q    No.  You would expect a nurse to know
 8   that a temperature elevation can be a sign
 9   of infection, correct?
10   A    Yes, I would expect that.
11   Q    All right.  An elevated pulse, Doctor,
12   nonspecific but can be a sign of infection,
13   correct?
14   A    As we went over the other parts of
15   this, in general, yes.
16   Q    Okay.  You'd expect the nurse to know
17   that as well?
18   A    I expect the nurse to recognize an
19   elevated pulse.
20   Q    As a potential sign of infection?
21   A    She may or may not.
22   Q    Well, Doctor, what is your expectation,
23   okay?  Would your expectation be that a
24   nurse who's caring for one of your patients
25   recognize an elevated pulse as nonspecific
0053
 1   but a potential sign of infection?  Is that
 2   your expectation, Doctor?
 3   A    Not necessarily.
 4   Q    Doctor, in the first 24 hours after
 5   delivery, what would be your range for a
 6   normal pulse?
 7             MR.JEFFERS:    Wait.  Just in
 8   that way --
 9             MR. JACOBSON:   Yeah.
10             MR. JEFFERS:   -- without
11   including other items such as being
12   preeclamptic, such as on magnesium sulfate
13   or anything else, just out of the blue?
14   BY MR. JACOBSON:
15   Q    All right, for this patient, Doctor,
16   what would you expect her pulse range to be
17   in the first 24 hours?
18   A    In this --
19   Q    The range of normal for this patient.
20   A    In this particular patient?
21   Q    Yes.
22   A    Between 60 and 120.
23   Q    Okay.  Is there any text that you can
24   cite me for that, Doctor?
25   A    No, sir.
0054
 1   Q    That's just your opinion, correct?
 2   A    That is my opinion given this patient's
 3   clinical circumstances.
 4   Q    What about elevated respiratory --
 5   well, what about this patient's clinical
 6   circumstances suggest to you that -- that
 7   120 would be the upper range of normal?
 8   A    I'm sorry.  Repeat that.
 9   Q    What about this patient's clinical
10   circumstances suggest to you that 120 would
11   be within the range of a normal pulse?
12   A    She was a woman recovering from the
13   delivery of her first child.  There was
14   extra bleeding noted at the time of
15   delivery.  She was given agents to try to
16   control that bleeding.  She was then put on
17   magnesium sulfate.  There is a whole range
18   of things that would contribute to what I
19   give you as what I would accept as normal.
20   Q    Would magnesium sulfate tend to elevate
21   her heart rate, Doctor?
22   A    It may or may not.
23   Q    What about her respiratory rate,
24   Doctor; would the magnesium sulfate tend to
25   elevate that?
0055
 1   A    In the initial use, no.
 2   Q    Okay.  At -- at some point, is it your
 3   testimony that it would tend to elevate a
 4   respiratory rate?
 5   A    No, sir.
 6   Q    Doctor, an elevated respiratory rate,
 7   is that a nonspecific sign of a potential
 8   sign of infection?
 9   A    As a hypothetical, it's a nonspecific
10   sign.
11   Q    Okay, but a potential sign of
12   infection, Doctor?
13   A    It's a potential sign of many things.
14   Q    Including infection, correct?
15   A    It could include infection.
16   Q    On a patient -- pardon me.  With a
17   patient who is on magnesium sulfate, you
18   would generally expect their respiratory
19   rate to be a little bit lower than normal,
20   correct?
21   A    No, that's not correct.
22   Q    What would the range of normal
23   respiratory rate be for this patient,
24   Doctor, being that she is on magnesium
25   sulfate in the first 24 hours?
0056
 1   A    I think 12 -- anywhere between 12 to 28
 2   could be normal.
 3   Q    Doctor, would you expect a nurse to be
 4   aware that an elevated respiratory rate is
 5   nonspecific but a potential sign of
 6   infection?
 7   A    No, I don't have that expectation.
 8   Q    All right.  All right, now, we know
 9   that the 11:30 labs, there was an abrupt --
10   pardon me, an abrupt drop in the white blood
11   count from 16,100 to 4600, correct?
12             MR. JEFFERS:   And we're speaking
13   of the 11:30 on June 26th?
14             THE WITNESS:   You're speaking of
15   the labs on June 25th, 2330?
16   BY MR. JACOBSON:
17   Q    Yeah, white blood count had dropped
18   from the previous reading of 16,100 to 4600,
19   correct?
20   A    That's what was reported, yes.
21   Q    Okay.  Now, Doctor, is that something
22   which is suggestive of infection?
23   A    No, sir.
24   Q    Okay, and why is that?
25   A    It doesn't suggest anything.
0057
 1   Q    Okay.  Is it, Doctor, what you would
 2   consider to be normal?
 3   A    Yes.
 4   Q    Okay.  In other words, Doctor, not just
 5   the absolute value, but the drop from five
 6   p.m. with a white blood count of 16,100 to
 7   11:30 p.m. of 4600 is a normal thing,
 8   correct?
 9   A    It can be in this patient.
10   Q    Okay.  Did -- did that -- Doctor, did
11   that -- well, strike that.
12             Dr. Hahn makes the statement in
13   his deposition on page 293 with respect to
14   the 11:30 labs.
15             MR. JEFFERS:   Do you have that
16   handy?
17   BY MR. JACOBSON:
18   Q    I'll just read it to you, Doctor.
19             MR. JEFFERS:   Well, I want him to
20   see it. Page 293.
21   BY MR. JACOBSON:
22   Q    Page 292, line 25.
23             MR. JEFFERS:   Page 292.
24   BY MR. JACOBSON:
25   Q    Line 25, the last line on 292.
0058
 1             MR. JEFFERS:   Wait a second.
 2             THE WITNESS:   I'm sorry.  Page 2
 3   --
 4             MR. JEFFERS:   Nine two, line 25.
 5             THE WITNESS:   Two nine two.
 6   BY MR. JACOBSON:
 7   Q    Now, we're referring now to the 11:30
 8   labs, and Dr. Hahn makes the statement, "I
 9   know for certain I wasn't given this
10   information because a first-year medical
11   student would have reacted to a change in
12   white blood cell count like that."  Do you
13   agree with Dr. Hahn's statement?
14             MR. JEFFERS:   Object.  Go ahead.
15             THE WITNESS:   No, I don't agree
16   with his statement.
17   BY MR. JACOBSON:
18   Q    Doctor, were the laboratory people
19   concerned with the drop in the white blood
20   count?
21   A    I don't know.
22             (At this time a discussion was
23   held off the record.)
24   BY MR. JACOBSON:
25   Q    Can we turn to the hematology report?
0059
 1   It's page 42 in the chart.  Now, Doctor,
 2   it's your testimony here, before we get to
 3   that, that as long as the absolute value of
 4   the white blood count is within normal
 5   limits, then, a drop is not concerning.
 6             MR. JEFFERS:   Object.
 7   BY MR. JACOBSON:
 8   Q    Or concerning, correct?
 9             MR. JEFFERS:   Object.  I don't
10   think that's necessarily what he said.
11   BY MR. JACOBSON:
12   Q    Well, I mean, Doctor, this -- this
13   white blood count dropped from 16,100 to
14   4600 within a six and a half -- a six and a
15   half hour period.  Is that something that
16   would concern you for a patient of yours?
17   A    In this particular patient, it does not
18   concern me.
19   Q    And why is that?
20   A    Because, given this particular
21   patient's circumstances, I don't think it
22   has any clinical significance.
23   Q    Okay.  Now, the lab, obviously, was
24   concerned because they checked and verified
25   the result, correct?  And if you look at
0060
 1   footnote number four, it says, "white blood
 2   count, hemoglobin and platelet results
 3   checked and verified," correct?
 4             MR. JEFFERS:   Objection.  There's
 5   a fact, but you prefaced it by saying they
 6   obviously were concerned.  I don't think you
 7   can put those together, and I object to the
 8   question.
 9   BY MR. JACOBSON:
10   Q    Let me rephrase it.  Do you know why,
11   in spite of the fact that the white blood
12   count's value was within the normal range,
13   that they checked it?
14   A    They checked a lot of things,
15   obviously: their white count, hemoglobin,
16   platelets.  They can recheck for a lot of
17   different reasons.
18   Q    Why did they undertake to do that on
19   their own, Doctor?
20   A    I have no idea.
21   Q    As a matter of fact, Doctor, they don't
22   tend to typically do that in any lab unless
23   the result is unusual, abnormal or
24   disconcerting, correct?
25             MR. JEFFERS:   Object.  Go ahead.
0061
 1             THE WITNESS:   No, I don't think
 2   you're correct at all.
 3   BY MR. JACOBSON:
 4   Q    Doctor, is a drop in -- in the white
 5   blood count from 16,100 at 5:00 to 4600 at
 6   11:30 a potential sign of infection?
 7   A    As I said, in this patient, no.
 8   Q    All right, Doctor.  Let's move on.
 9   All right.  Let me just follow up on that.
10   Why is it not, Doctor?
11   A    Given this patient's circumstances, I
12   don't think it has any clinical significance.
13   Q    What about this patient's circumstances?
14   A    That she was postpartum, that she just
15   had a baby, that she was on magnesium
16   sulfate, that she was still receiving IV
17   fluids; there is a host of reasons why I
18   think that has no relevance.
19   Q    Okay.  So, you think it's of no
20   relevance and Dr. Hahn thinks that even a
21   first-year medical student would react to
22   that, correct?
23             MR. JEFFERS:   Objection.  That's
24   what Dr. Hahn said.  Now, you can't get --
25   ask him to say that's what Dr. Hahn thinks.
0062
 1   BY MR. JACOBSON:
 2   Q    So, it's your testimony here, and I
 3   just want to make sure I understand it, that
 4   this drop does not concern you, and you feel
 5   it's of no relevance, correct?
 6   A    That's correct.
 7   Q    All right.  All right, now, Doctor,
 8   were the nurses concerned with the patient's
 9   urine output shortly before midnight on the
10   25th?
11   A    Yes.
12   Q    Okay.  Would you expect, Doctor, a
13   nurse -- strike that.  Is reduced urine
14   output, Doctor, a potential sign of
15   infection?
16   A    Only in the very broadest of, you know,
17   hypothetical situations.
18   Q    Okay.  Would you agree with me, Doctor,
19   that reduced urine output is nonspecific but
20   can be a sign of infection?
21   A    No.
22   Q    What's incorrect about that statement?
23   A    It's not a sign of infection.
24   Q    Can infection, Doctor, produce reduced
25   urine output?
0063
 1   A    In -- in the severe forms, infections
 2   can produce reduced urine output, yes.
 3   Q    So, Doctor, the converse of that is
 4   true as well.
 5             MR. JEFFERS:   Pardon me?
 6   BY MR. JACOBSON:
 7   Q    Reduced urine output can be a symptom
 8   or sign of infection, correct?
 9             MR. JEFFERS:   Sorry.  I need that
10   back.  I did not hear your first -- you're
11   talking a lot with your hand over your
12   mouth, by the way.
13   BY MR. JACOBSON:
14   Q    Let me just rephrase the question.
15   Doctor, if, indeed, infection can produce
16   reduced urine output, then, reduced urine
17   output can be a symptom of infection,
18   correct?
19   A    No, sir.
20   Q    Okay.
21   A    That does not follow logically.
22   Q    Okay, and why is that?
23   A    Because it isn't true.
24   Q    What's wrong with the logic there?
25             MR. JEFFERS:   If it isn't true,
0064
 1   he just told you.  If he believes it's not
 2   true, then your logic fails or your -- or
 3   you're illogical.
 4   BY MR. JACOBSON:
 5   Q    If that's your testimony, Doctor, I
 6   just want to make sure I understand it.
 7   Reduced urine output in a patient is not a
 8   potential sign of infection?
 9   A    That's correct.
10   Q    Okay, and is it something that would
11   concern you, Doctor, reduced urine output in
12   a patient?
13   A    Given the patient's circumstances, it
14   may.
15   Q    Okay.  Well, let's say we have a
16   patient who at about 5:00 p.m. on the 25th
17   was putting out over 100 ccs of urine per
18   hour, and when we get near midnight is
19   putting out about 30 ccs of urine per hour.
20   Is that -- would that concern you, Doctor?
21   A    Nope.
22   Q    Why is that?
23   A    It sounds normal.
24   Q    What's your range of normal for a urine
25   output?
0065
 1   A    Anywhere from 20 to sometimes hundreds
 2   of ccs, given the patient's circumstances.
 3   These are all hypothetical questions.
 4   Q    And -- and a gradual decrease in urine
 5   output over that period of time does not
 6   concern you either, correct, Doctor?
 7             MR. JEFFERS:   He's now saying
 8   gradual.
 9   BY MR. JACOBSON:
10   Q    Decrease in urine output between 5:00
11   p.m. and 11:30 p.m. would not concern you,
12   correct?
13   A    Are we talking about this particular
14   patient?
15   Q    Yes.
16   A    Or in general?
17   Q    This patient.
18   A    No, sir, it does not concern me.
19   Q    Doctor, rectal and vaginal pressure.
20   A    Yes, sir.
21   Q    A potential sign of infection?
22   A    No, sir.
23   Q    Why is that?
24   A    It isn't.
25   Q    So, an infection will not cause rectal
0066
 1   pressure?
 2   A    Not in the first 24 hours postpartum.
 3   Q    Well, will an infection cause vaginal
 4   pressure?
 5   A    Will an infection cause vaginal
 6   pressure?
 7   Q    Yeah.
 8   A    In the first 24 hours postpartum?
 9   Q    Yes.
10   A    Or are we talking about any time?
11   Q    In the first 24 hours postpartum.
12   A    Never that I've seen.
13   Q    Okay, and why is that, Doctor?
14   A    Why?  It doesn't do it.
15   Q    Okay.  So, an infection from time to
16   time will cause rectal or vaginal pressure
17   but not in the first 24 hours postpartum; is
18   that correct?
19   A    If it's related to the postpartum
20   period, that's correct.
21   Q    Okay.  Well, Doctor, what if that
22   infection began to seed when the membranes
23   ruptured; then -- then, is rectal or vaginal
24   pressure potentially a sign of infection?
25             MR. JEFFERS:   Objection.
0067
 1             THE WITNESS:   No, sir.
 2   BY MR. JACOBSON:
 3   Q    Why is that?
 4   A    It doesn't happen.
 5   Q    Why does it take -- why does the body
 6   physiologically, can you explain to me, take
 7   longer to produce rectal or vaginal pressure
 8   as a sign of infection?  First of all, how
 9   does an infection in any length of time,
10   Doctor - let's start with that - produce
11   rectal pressure or vaginal pressure?
12   A    By forming an abscess.
13   Q    Okay.  Now, will more virulent bugs
14   tend to form an abscess quicker, Doctor?
15   A    May or may not.
16   Q    So, certainly it's conceivable, Doctor,
17   that, even if the infection is seeding at
18   the time of delivery, that a virulent bug
19   will form an abscess within the first 24
20   hours, correct?
21             MR. JEFFERS:   Objection.
22             THE WITNESS:   No, sir, that's not
23   correct.
24   BY MR. JACOBSON:
25   Q    Distended abdomen, Doctor, a potential
0068
 1   sign of infection?
 2   A    In this particular patient or in
 3   general?
 4   Q    Let me just put it to you this way,
 5   Doctor.  In general, Doctor, a distended
 6   abdomen is a sign which is closely
 7   associated with infection, in general,
 8   correct?
 9   A    In -- in people with intra-abdominal
10   infections, that can be the case.
11   Q    Well, Doctor, in the general
12   population, a distended abdomen is closely
13   associated with infection, correct?
14   A    No, sir.
15   Q    In a patient who walks into an
16   emergency room with a distended abdomen,
17   what are the -- is -- is intra-abdominal
18   infection on the top three in the
19   differential?
20   A    Yes, sir, intra-abdominal infection is
21   in the top three.
22   Q    So, then, Doctor, indeed, a distended
23   abdomen is a potential sign of infection,
24   correct?
25   A    No, sir.  I will not accept that term
0069
 1   stated that way.
 2   Q    What's wrong with that statement?
 3   A    It just isn't.
 4   Q    What do you mean by that, Doctor?  That
 5   --
 6   A    If I see a distended abdomen, I don't
 7   think of -- in a postpartum patient, I do
 8   not think of infection.
 9   Q    And why is that?
10   A    Because it doesn't happen.
11   Q    Okay.  Doctor, with respect to the
12   hospitals that you now have privileges at,
13   the Lake Hospital System, they're community
14   hospitals.  We've already discussed that,
15   correct?
16   A    Yes, sir.
17   Q    Doctor, has -- have you ever had a
18   nurse tell you that she's worried about a
19   patient's possibly having an infection?
20   A    Yes, sir.
21   Q    Okay, and that's good nursing care if
22   indeed the nurse has those concerns, correct?
23   A    It can be.
24             MR. JEFFERS:   Hold it a second.
25   You might want to -- no, seriously, I want
0070
 1   to tell you something.  You might want to
 2   change chairs and put that over on the side
 3   over there, and the reason is, is John Baker
 4   broke two of those doing that, but John
 5   Baker weighs somewhat more than you, but I
 6   -- I think, take that chair and just dump it
 7   upside down so no one else sits on it.
 8             MR. SCHOBERT:  I'll just put it
 9   here.
10             MR. JEFFERS:   No, no.  Turn it
11   upside down.
12             MR. SCHOBERT:  All right.
13             THE WITNESS:   Did it break?
14             MR. JEFFERS:   I don't know, but I
15   heard a fracture, and I wouldn't bat -- if
16   it was my bat for baseball, I wouldn't hit
17   with it.
18             MR. SCHOBERT:  Go ahead.
19             MR. JEFFERS:   Don't worry about
20   it.
21             MR. SCHOBERT:  I don't want to
22   interrupt you.
23             MR. JEFFERS:   The more you break,
24   the happier I am with these chairs.
25   BY MR. JACOBSON:
0071
 1   Q    Doctor, if a nurse who you're working
 2   with has a concern that a patient has an
 3   infection that has not been diagnosed and
 4   treated, then, you would expect the nurse to
 5   communicate her concerns to you, correct?
 6             MR. JEFFERS:   Objection.  I think
 7   we've gone over this one ad nauseum.  Go
 8   ahead.
 9             THE WITNESS:   As a hypothetical,
10   yes.
11   BY MR. JACOBSON:
12   Q    Certainly, Doctor, you wouldn't expect
13   any less of the nurses at Parma Hospital;
14   would you?
15   A    No, sir.
16   Q    Doctor, has a nurse ever asked you to
17   come in?  Doctor, I think you better come in
18   and see this patient?
19             MR. JEFFERS:   Objection.  That's
20   the -- that's the broadest comment I've ever
21   heard.
22   BY MR. JACOBSON:
23   Q    In a postpartum patient, Doctor, that
24   you're caring for, have you ever had a nurse
25   say:  Doctor, I think you should come in and
0072
 1   see this patient?
 2   A    Yes, sir.
 3   Q    In other words, Doctor, we can agree
 4   that, if the nurse feels that a doctor
 5   should come in to assess the patient, that
 6   it's good nursing care for her to tell that
 7   to the doctor, correct?
 8   A    If the nurse feels strongly that she
 9   wants the patient seen by the physician, she
10   can make that request.
11   Q    More than she can make the request; if
12   she feels that the doctor should come in and
13   see the patient, she has a duty to her
14   patient to communicate that to the doctor,
15   correct?
16   A    She can communicate that to the doctor,
17   yes.
18   Q    Doctor, does she have a duty to -- if
19   -- once again, with all due respect, Doctor,
20   your answers are not responsive to my
21   questions.  You keep saying "she can."  I
22   want to know if she has a duty.  I'll
23   restate the question once again.
24             If a nurse feels that a doctor
25   should come and see the patient, does she
0073
 1   have the duty to the patient to communicate
 2   that to the doctor?
 3   A    Yes.
 4   Q    Okay, and you would expect nothing less
 5   in that regard of the nurses at Parma,
 6   correct?
 7   A    I would expect nothing less.
 8   Q    Now, Nurse Prokop testified that at the
 9   shift change between 11 and 12:00 p.m. on
10   the 25th, that she and her predecessor were
11   concerned because the patient did not look
12   well.  Did they have a duty to communicate
13   that to Dr. Hahn?
14             MR. JEFFERS:   What time was that?
15   BY MR. JACOBSON:
16   Q    Between 11:00 p.m. on the 25th.
17             MR. SCHOBERT:  I'll object.
18             MR. JEFFERS:   Eleven on the
19   25th.  What page is it in the depo, Dave?
20             MR. JACOBSON:   Page 23 of 12.
21             MR. JEFFERS:   Of which one,
22   Prokop?
23             MR. JACOBSON:   Nurse Prokop.
24             MR. JEFFERS:   Okay.  We're going
25   to have to have the question again, if you
0074
 1   don't mind, please.
 2   BY MR. JACOBSON:
 3   Q    Well, Nurse Prokop's testimony on page
 4   23, she's asked, "Did you have any
 5   conversations with Debbie about Mrs.
 6   Williams, specifically?
 7             "Answer: Yes I did."
 8             "Question:  Tell me about those
 9   conversations.
10             "Answer:  Okay.  In the course of
11   the report, it was just apparent from what
12   -- from her shift that she was not really
13   happy, you know, with where she was at that
14   point.  She had been, you know,
15   preeclamptic, and we knew that, and we still
16   had mag sulfate running.  So, she just --
17   the thing that really evolved out there was
18   the normal symptoms of preeclampsia, but she
19   was still very restless at that point at the
20   time of the report and was just not happy
21   with the way, you know, she was -- she was
22   looking.  Her outcome was not terrific, you
23   know, in the normal, you know, range, hoping
24   for a little bit more, and those were
25   probably the two things that we discussed
0075
 1   most at that time."
 2   Q    Now, with respect to those concerns,
 3   the concern that the patient wasn't looking
 4   good, the patient was restless, the
 5   patient's urine output was minimal, did
 6   these nurses have a duty to communicate
 7   these concerns to Dr. Hahn?
 8             MR. JEFFERS:   I want to object
 9   because the record shows at 0030 they called
10   the house doctor in and discussed it, and
11   then Dr. Hahn was called.  So --
12   BY MR. JACOBSON:
13   Q    And my question is, with all due
14   respect, John:  did they have a duty to
15   communicate those concerns that we just read
16   over to Dr. Hahn?
17   A    I think they had a duty to communicate
18   to someone, which they did.
19   Q    Did they have a duty to communicate
20   those concerns to Dr. Hahn?
21   A    Through the chain of command, yes.
22   Q    Okay.  So, whether Dr. Hahn got that
23   information from Dr. Hsieh or from Nurse
24   Prokop, we can agree that Dr. Hahn should
25   have gotten that information from some
0076
 1   source.  We're in agreement on that,
 2   correct?
 3   A    Yes.
 4   Q    Now, is there any testimony that you've
 5   read or any note where Dr. Hahn indicates
 6   that he was told or whether a nurse
 7   indicates that she told Dr. Hahn that they
 8   were concerned about the patient's
 9   appearance, about the patient's urine
10   output, about the patient's restlessness?
11   A    What's the question again?
12             MR. JEFFERS:   Just read it back
13   why don't we, Luanne, please.
14             (At this time the question was
15   read back.)
16             THE WITNESS:   Yes.
17   BY MR. JACOBSON:
18   Q    Well, Doctor, is -- is reporting the
19   level of urine output the same as expressing
20   concern?
21             MR. JEFFERS:   Wait.  Are you
22   segmenting that out now?
23             MR. JACOBSON:  Actually, you
24   know, I'm going to strike that and then move
25   on.
0077
 1             MR. JEFFERS:   Okay.
 2   BY MR. JACOBSON:
 3   Q    Doctor, what I want to do now is turn
 4   to what you consider the appropriate
 5   threshold for prophylactic and empiric
 6   treatment of infection.  Do you understand
 7   what I mean by that?
 8   A    No.
 9   Q    There are times, Doctor, when you have
10   a reasonable suspicion of infection that
11   it's not been demonstrated.  You encounter
12   that in patients from time to time, correct?
13   A    No.
14   Q    You've never had a patient where you've
15   had a suspicion that the patient has an
16   infected -- an infection?
17   A    Well, define "suspicion."  At what
18   level of clinical presentation?  You're
19   using words here that just have absolutely
20   no meaning to me as a practicing physician.
21   Q    How about this.
22   A    If you'd use a reasonable term, maybe I
23   could give you a reasonable answer.
24   Q    How about this, Doctor:  you have a
25   patient.  You think there's a possibility
0078
 1   the patient has an infection.  Have you ever
 2   encountered that situation?
 3   A    Yes, sir.
 4   Q    Okay, and there are times where you
 5   will treat that infection empirically before
 6   you've proven it via culture, correct?
 7   A    What do you mean empirically?  Define
 8   that term for me.
 9   Q    Giving a broad spectrum antibiotic.
10   A    When I have clinical suspicions?
11   Q    Yes.
12   A    With or without laboratory
13   confirmation?
14   Q    Yes.
15   A    I will sometimes treat infections, yes.
16   Q    All right.  Now, what I want to discuss
17   with you, Doctor, is what your threshold is
18   in terms of suspicion --
19   A    Yes.
20   Q    -- for infection, where you feel that
21   empiric treatment is appropriate.
22   A    Would you drop the word "empiric"
23   because I won't answer to anything
24   concerning empiric.
25   Q    How about -- how about prophylactic?
0079
 1   A    Prophylactic is a totally different
 2   subject, a different spectrum of patients.
 3   Q    Well, let's just talk about treating
 4   it, Doctor, with an antibiotic.
 5   A    Okay.
 6   Q    Okay?  What I want to explore, Doctor,
 7   is what your threshold is.  Can you explain
 8   to me, Doctor, what degree of suspicion you
 9   need to have before you feel it's
10   appropriate to treat an infection with
11   antibiotics?
12             MR. JEFFERS:   Is the
13   hypothetical:  without any more clinical
14   information?
15             MR. JACOBSON:   In general,
16   Doctor.
17             MR. JEFFERS:   That -- that -- I
18   don't know that that's an answerable
19   question.
20   BY MR. JACOBSON:
21   Q    For pueperal infections.
22             MR. JEFFERS:   Pardon me?
23   BY MR. JACOBSON:
24   Q    For pueperal infections.
25   A    Post-partum patients?
0080
 1   Q    Yes.
 2   A    Okay.
 3   Q    Tell me some of the factors, Doctor,
 4   that you'd consider in what your threshold
 5   would be for giving antibiotics.
 6   A    The patient's prenatal course.
 7   Q    Okay.
 8   A    The patient's -- what she brings to the
 9   pregnancy, what has gone on during the
10   pregnancy.  This answer could take a long
11   time, you understand.
12   Q    So, one thing you're looking for are
13   risk factors for infection in the prenatal
14   course and what happened during delivery,
15   correct?
16   A    I might be, yes.
17   Q    Okay.  Well, that's what you've
18   described, basically, the patient's prenatal
19   course and what happened during delivery.
20   You're looking for risk factors there,
21   correct?
22   A    You're using the term, risk factors.  I
23   didn't use that word.
24   Q    Well, is that something you're looking
25   for, Doctor, risk factors for infection?
0081
 1   A    I may or may not.  You used that word.
 2   I was just telling you what I base my
 3   decisions on.
 4   Q    Well, let me just put it to you this
 5   way, Doctor:  does the reasonable physician,
 6   when they are attempting to determine
 7   whether or not to treat a patient with
 8   antibiotics, consider amongst other things a
 9   patient's risk factors for infection?
10   A    And what -- what do you mean by "risk
11   factors for infection"?
12   Q    Do you understand what the term, risk
13   factor, means, Doctor?
14   A    Yes, sir.
15             MR. JACOBSON:  All right.  Can
16   you read back the question, then, please?
17             (At this time the question was
18   read back.)
19             MR. JEFFERS:   My objection is,
20   you two may be using different -- different
21   definitions for risk factor.
22             THE WITNESS:   I was telling you
23   the factors that went into my making a
24   decision about a pueperal infection, and I
25   said the prenatal course.  You introduced
0082
 1   the term, risk factors.  I would take into
 2   consideration a patient's prenatal course
 3   and things that she may or may not have had
 4   during the pregnancy.
 5   BY MR. JACOBSON:
 6   Q    What about the patient's prenatal
 7   course are you looking for, Doctor?
 8   A    The previous medical condition she may
 9   have had, previous treatments she may have
10   had, previous surgeries she may have had,
11   her whole medical history.
12   Q    So --
13   A    And her course during the pregnancy.
14   Q    All right.  So, you're looking, Doctor
15   -- if you don't like the term, risk
16   factors, I guess you're looking for
17   opportunity for bacteria to invade, correct?
18   A    No, sir, that's not what I'm looking
19   for.  I'm telling you how I evaluate a
20   patient for a possible pueperal infection.
21   I look at her prenatal course.  Then I look
22   at the intrapartum course and what things
23   may or may not have gone on during her labor
24   and delivery process.
25   Q    Fair enough.  And in the intrapartum
0083
 1   course, Doctor, are you considering risk
 2   factors for infection?  Is that what you're
 3   looking for?
 4   A    I'm looking for issues that may play a
 5   role in the acquiring of infection.
 6   Q    That's fine with me, okay.  Issues that
 7   may play a role in acquiring an infection,
 8   I'll just use that terminology instead.
 9   And, Doctor, does the reasonable physician
10   when attempting to determine whether a
11   patient has an infection or a potential
12   infection consider issues which may play a
13   role in acquiring infection?
14   A    Yes.
15   Q    Okay.  Once again, then, Doctor, would
16   you describe to me in terms of your level of
17   certainty when you prescribe antibiotics?
18   For example, Doctor, if you have what you
19   consider to be a reasonable suspicion that a
20   patient has an infection, will you prescribe
21   antibiotics?
22             MR. JEFFERS:   No other clinical
23   information?
24             MR. JACOBSON:   Yeah.
25   BY MR. JACOBSON:
0084
 1   Q    I mean, if the clinical information,
 2   Doctor, is such that you have a reasonable
 3   suspicion that the patient has an infection,
 4   will you prescribe antibiotics?
 5   A    Yes, sir.
 6   Q    All right, and we can agree, Doctor,
 7   that that would be a -- that's what the
 8   reasonable physician would do.  When a
 9   reasonable physician has a reasonable
10   suspicion that the patient has an infection,
11   he'd prescribe antibiotics, correct?
12   A    Yes, sir.
13   Q    All right, and one thing that you're
14   doing, Doctor, is, you're doing a
15   risk/benefit analysis which is something
16   that you're doing all the time, correct?
17   A    I balance treatments versus hazards of
18   those treatments in patients every single
19   day.
20   Q    Okay, and, Doctor, in the puerperal
21   period, the -- an infection can have a high
22   degree of morbidity, correct?
23   A    Would you define that, please?
24   Q    There are bacteria which are associated
25   with puerperal infections which have a high
0085
 1   degree of morbidity, correct?
 2   A    What does that mean, a high degree of
 3   morbidity?
 4   Q    Let me -- let me strike that question.
 5   All right.  Let me just go back to this
 6   reasonable suspicion, okay, and our
 7   agreement that a reasonable physician, when
 8   they have a reasonable suspicion of
 9   infection, will -- will treat with
10   antibiotics.  And let's talk now
11   specifically about this patient and -- and
12   when, indeed, there's a reasonable suspicion
13   of infection, okay?  Now, when do you feel
14   that there's a reasonable suspicion of
15   infection in this patient?
16   A    I think some time after nine a.m. on
17   the 26th.
18   Q    Okay.  All right, let's -- let's then
19   explore, Doctor, some of the things that
20   were going on.  First of all, Doctor, to use
21   your terminology, issues that may play a
22   role in acquiring infection, certainly,
23   Doctor, the longer one's rupture of
24   membranes precedes delivery, the greater
25   risk there is for an infection, correct?
0086
 1   A    That's been reported in the literature,
 2   yes.
 3   Q    Okay.  The number of vaginal exams that
 4   a patient has had, Doctor, the risk for
 5   infection increases with the number of
 6   vaginal exams that the laboring mother has,
 7   correct?
 8   A    That's been reported also, yes.
 9   Q    Okay.  Doctor, what about the cervical
10   suppository, is there an association with a
11   greater risk of infection when a patient has
12   a cervical suppository placed?
13   A    Not that I'm aware of.
14   Q    Okay.  What about delivery which
15   utilizes instrumentation, Doctor,
16   association with a greater risk of infection?
17   A    Not necessarily.
18   Q    Okay.  Doctor, the literature is
19   replete with references to a high risk of
20   infection when instrumentation is used;
21   isn't that true?
22   A    You're incorrectly quoting the
23   literature, sir.
24   Q    Does the literature report a higher
25   risk for infection, Doctor, when
0087
 1   instrumentation is used?
 2   A    The instrumentation you're referring to
 3   are forceps.
 4   Q    Uh-huh.
 5   A    That was not utilized in this patient.
 6   Q    So, Doctor, there is no increased
 7   incidence of infection with the use of
 8   vacuum extraction?
 9   A    I didn't say that.
10   Q    Okay.  Is there an increased incidence
11   of infection with vacuum extraction?
12   A    The answer is no, sir.
13   Q    What about episiotomy, Doctor;
14   increased incidence of infection in a
15   patient that has an episiotomy?
16   A    It depends on which kind of study you
17   want to look at.
18   Q    Doctor, does the literature report an
19   increased risk of infection in a patient
20   with an episiotomy?
21   A    At this time in the United States, I
22   don't think that can be studied.
23   Q    Do you believe, Doctor, that a patient
24   who has an episiotomy has an increased risk
25   of infection?
0088
 1   A    No, sir.
 2   Q    Doctor, the process of -- of delivery
 3   itself, vaginal delivery is an issue which
 4   may play a role in acquiring infection,
 5   correct?
 6   A    It can, yes.
 7   Q    And the reason for that, Doctor, is
 8   that, during the delivery process, tissues
 9   are exposed to bacteria which they are not
10   usually exposed to, correct?
11   A    As a -- as a hypothetical thing, it is
12   one of many factors that may play a role.
13   Q    Certainly, Doctor, there's a higher
14   incidence of infection in a -- in a patient
15   who's just had a vaginal delivery than in
16   the general population of people, correct?
17             MR. SCHOBERT:  Objection.
18             MR. JEFFERS:   I'll enter an
19   objection.
20             THE WITNESS:   I'm not sure of
21   that.
22   BY MR. JACOBSON:
23   Q    Doctor, a strep A -- strike that.  What
24   -- what was the bacteria that was found in
25   this patient by culture?
0089
 1   A    By culture?
 2   Q    Yes.
 3   A    Strep A.
 4   Q    Okay.  Now, is that an aerobic or
 5   anaerobic?
 6   A    Aerobic.
 7   Q    Okay.  Is it part of the normal --
 8   normal flora of the female genital tract,
 9   Doctor, or is it exogenous?
10   A    It can be found there normally.
11   Q    Do you -- do you know the answer to
12   that question, Doctor, or are you guessing?
13   A    I'm sorry?
14   Q    Do you know the answer to that question?
15   A    It can be found in women who have no
16   clinical disease, and I'm defining that as
17   normal, then.
18   Q    Doctor, do you have -- can you cite me
19   to any literature that supports that
20   statement?
21   A    Not off the top of my head.
22   Q    As a general rule, Doctor, is strep A
23   part of the normal flora and fauna found in
24   a female genital tract?
25   A    It can be at some time.
0090
 1   Q    Is it rare?
 2   A    It's unusual, perhaps.
 3   Q    All right.  So, Doctor, before I move
 4   on, the -- the factors that would increase
 5   this woman's risk for infection beyond that
 6   of the general population would be the fact
 7   that she's in the process of having a baby,
 8   that she's had ruptured membranes and that
 9   she's had vaginal exams, correct?  Those
10   three things I think we agree on.
11   A    We agree that ruptured -- that ruptured
12   membranes for a prolonged period of time was
13   a risk factor for infection; that multiple
14   vaginal exams was a risk factor for
15   infection.  I did not state that I thought
16   they were a big risk factor in this patient.
17   Q    What -- when you say "prolonged," what
18   would be the definition of "prolonged,"
19   Doctor?
20   A    More than 24 hours.
21   Q    Okay, and -- and, Doctor, once again --
22   and we did agree that -- that in the process
23   of giving birth, there are tissues that are
24   exposed to bacteria that they're typically
25   not exposed to, correct?
0091
 1   A    I'm not sure I agreed to that
 2   particular statement.  I mean --
 3   Q    Do bacteria have access, for example,
 4   to the uterus, bacteria that typically do
 5   not have access to the uterus?
 6   A    They may.
 7   Q    Well, that's a fact; isn't it, Doctor,
 8   because the cervix is open, and there's
 9   access to the uterus from without, bacteria
10   can get to the uterus that typically will
11   not, correct?
12   A    Possibly, yes.
13   Q    I'll move on, Doctor, but the point I
14   want to make here is that a woman who has a
15   vaginal delivery who has rupture of
16   membranes 11 hours before, who's had vaginal
17   exams, and -- and just by virtue of the fact
18   that she's giving birth to a baby is
19   somebody who is at somewhat increased risk
20   for infection above that of the general
21   population, yourself, me, Mr. Jeffers
22   sitting here today, correct?
23             MR. JEFFERS:   I.e. a person who's
24   not pregnant like you, me or myself, or
25   hopefully not?
0092
 1             MR. SCHOBERT:  Objection.
 2             THE WITNESS:   As a hypothetical,
 3   yes.
 4   BY MR. JACOBSON:
 5   Q    Okay, and that's something, Doctor,
 6   that an obstetrician should be cognizant of
 7   -- cognizant of when attempting to determine
 8   whether a patient has an infection or not; a
 9   woman in the puerperal period, an
10   obstetrician should be cognizant of the fact
11   that that woman has a slightly increased
12   risk for infection over the general
13   population, correct?
14   A    Yes.
15             MR. JEFFERS:   Objection.
16             THE WITNESS:   Yes.
17             MR. JACOBSON:  Did you get the
18   answer?
19   BY MR. JACOBSON:
20   Q    Now, let's -- but certainly, Doctor,
21   when we get back to whether this patient has
22   a reasonable suspicion of infection, the
23   fact that she's giving a baby, that in and
24   of itself does not give rise to a reasonable
25   degree of infection in the patient, and the
0093
 1   other things, correct?
 2   A    What do you mean, "the other things"?
 3   Q    Well, there has to be other clinical
 4   evidence or laboratory evidence of
 5   infection.  Let me strike that question and
 6   let me move on.
 7             Doctor, at 11 a.m. there's a
 8   complete blood count with a white count of
 9   17,300.  Why don't we turn to those labs.
10   A    All right.  I'm sorry.  What time?
11   Q    11:30 a.m. on the 25th.
12   A    On the 25th?
13             MR. JEFFERS:   Wait.
14             THE WITNESS:   The 25th, yes.
15             MR. JEFFERS:   Oh, okay.
16             THE WITNESS:   Yes, sir.
17   BY MR. JACOBSON:
18   Q    Doctor, is there a left shift in this
19   patient at that time?
20   A    Her white count is 17.3 as it's
21   reported.
22             MR. JEFFERS:   This is on the 25th
23   we're talking about?
24             MR. JACOBSON:   Yes.
25             MR. PARIS:      Here on the 24th,
0094
 1   11 a.m., are you talking about?
 2             MR. JACOBSON:   Oh, I'm sorry.
 3             MR. JEFFERS:   There's a 24th lab
 4   before --
 5             MR. PARIS:     Hold on.
 6             MR. JEFFERS:   -- delivery.
 7   BY MR. JACOBSON:
 8   Q    I'm talking about 11:00 a.m. on the
 9   25th.
10   A    Yes, sir.
11   Q    Yeah, now, Doctor, is there a left
12   shift here?
13   A    A little bit, yes.
14   Q    Okay.  So, my next question was to ask
15   you to turn -- to characterize it in terms
16   of degree.  Mild, moderate, severe, you'd
17   call it mild?
18   A    Mild.
19   Q    Okay, and bandemia, Doctor?
20   A    Eight percent is reported.
21   Q    Okay, and is that mild, moderate or
22   severe?
23   A    Mild.
24   Q    Okay.  What is your definition of -- of
25   bandemia, Doctor, in the puerperal period?
0095
 1   A    Well, you have to say a lot more than
 2   that.
 3   Q    Okay.  Do you have --
 4   A    And it can be perfectly normal and, in
 5   fact, is commonly seen in people undergoing
 6   vaginal delivery.
 7   Q    Do you have, Doctor, any definition of
 8   -- of what constitutes bandemia?
 9   A    In the immediately postpartum --
10   Q    Yes.
11   A    -- or intrapartum patient?
12   Q    Yes.
13   A    No, sir.
14   Q    Doctor, at 5:00 p.m., the labs, would
15   you characterize the degree of left shift
16   and bandemia, please?
17   A    The lab report at 1700 on the 25th, is
18   that what you're referring to?
19   Q    Yes.
20   A    Her white blood cell count was 16.1 as
21   reported.  Bands were 13 percent.
22   Neutrophils were 75 percent.
23   Q    Mild, moderate, severe?
24   A    (At this time the witness shrugged his
25   shoulders.)
0096
 1   Q    Characterize it as you --
 2   A    In the postpartum patient, in this
 3   particular patient, mild.
 4   Q    Yes, okay, and the degree of bandemia,
 5   Doctor?
 6   A    It doesn't set off any bells and
 7   whistles.
 8   Q    Mild?
 9   A    Yes, sir.
10   Q    All right.
11             MR. JEFFERS:   Is he falling apart
12   at the seams?
13   BY MR. JACOBSON:
14   Q    All right, Doctor.  At 7:25, there was
15   a fever of 101.6, correct?
16             MR. JEFFERS:   Do you want to
17   check that?
18   BY MR. JACOBSON:
19   Q    Is that right?
20   A    Yes, yes, sir.
21   Q    All right.  Now, was the patient on any
22   anti-pyretics at the time?
23   A    She had a standing Tylenol order.
24   Q    Okay.  Would that tend to reduce the
25   fever?
0097
 1   A    It can.
 2   Q    Okay.  Doctor, had the patient had any
 3   ice packs prior to that time?
 4             MR. JEFFERS:   What time do you
 5   have?  What time did you say?  I'm sorry.
 6   BY MR. JACOBSON:
 7   Q    Prior to 7:25, Doctor.
 8             MR. JEFFERS:   You're talking
 9   about p.m.?
10             MR. JACOBSON:   Yes.
11             MR. JEFFERS:   Okay, because we've
12   usually been using military time.
13             MR. JACOBSON:   Pardon me.
14             MR. JEFFERS:   And 7:25 would
15   connote a.m.
16             May I show him?
17             MR. PARIS:     Please.
18             MR. JEFFERS:   Here's ice packs.
19             THE WITNESS:   Right, that's not
20   until after that, though.
21   BY MR. JACOBSON:
22   Q    Well, Doctor, there was some ice, I
23   believe, to the fundus and perineum prior to
24   that time, about five p.m.
25             MR. JEFFERS:   What time now?
0098
 1             MR. JACOBSON:   5:00 p.m.
 2             MR. JEFFERS:   Okay, seven.  I
 3   have 1725, but I think it was -- or I have
 4   -- no, I have 2000.
 5             THE WITNESS:   2000 was the time I
 6   was looking at.
 7             MR. JEFFERS:   I don't have 1725.
 8   BY MR. JACOBSON:
 9   Q    Doctor, if, indeed, there was an ice
10   pack placed on the fundus and perineum at
11   5:00 and remained there --
12   A    Okay.
13   Q    -- would that tend to depress the
14   temperature?
15   A    No, sir.
16             MR. JEFFERS:   Location?  I'm
17   sorry.  Location?
18   BY MR. JACOBSON:
19   Q    Fundus and perineum.  Would it tend to
20   depress?
21   A    No, sir, it would not.
22   Q    Why is that?
23   A    It doesn't do that.
24   Q    Okay.  Ice packs to the back, Doctor,
25   and neck, would that tend to depress the
0099
 1   temperature?
 2   A    No, sir.
 3   Q    Okay.  So, ice packs are not going to
 4   -- Doctor, would ice anywhere tend to
 5   depress the temperature?
 6   A    Covering her whole body, yes, sir.
 7   Q    Okay, but in one spot anywhere on the
 8   body, the answer -- your answer is no?
 9   A    That's correct.
10   Q    What about, Doctor, what about cold
11   rags placed on the forehead and the back of
12   the neck; would that tend to depress the
13   temperature?
14   A    No, sir.
15   Q    All right.  Doctor, if the patient had
16   not been on Tylenol, would you expect her
17   fever at 7:30 to be higher?
18   A    No, sir.
19   Q    Why is that?
20   A    I don't expect it to be higher.
21   Q    Okay, but -- but one thing that Tylenol
22   does do will -- is to lower the fever,
23   correct?
24   A    Yes, sir.
25   Q    Okay.  Doctor, if you have a patient
0100
 1   who's in the puerperal period who's
 2   developing a fever, would you stay away from
 3   anti-pyretics to see where the fever is
 4   going?
 5   A    I may or may not.
 6   Q    Okay.  That's something you have done
 7   in the past, correct?
 8   A    On occasion.
 9   Q    Okay.  Why do you do that?
10   A    To see if they're developing a fever.
11   Q    And you would stay away from Tylenol
12   until you see what level that fever is going
13   to reach, correct?
14             MR. JEFFERS:   Under that
15   circumstance.
16   BY MR. JACOBSON:
17   Q    You've done that in the past, correct?
18   A    Under those -- under a certain
19   circumstance, and as the patient's clinical
20   situation evolves, then, I may change it,
21   reinstitute it.
22   Q    Uh-huh, and you might have done that in
23   this patient as well, correct?
24   A    No, sir, I would not have done that in
25   this patient.
0101
 1   Q    And why is that?
 2   A    There was no indication.
 3   Q    Okay, and, Doctor, in situations where
 4   you have done that in the past -- in the
 5   past, what was the indication?
 6   A    The patient was sick.
 7   Q    Okay.  General malaise?
 8   A    That may have been present.
 9   Q    Okay.  This patient did not have that?
10   A    I'm sorry?
11   Q    This patient was not sick?
12   A    This patient did not have clinical
13   evidence of infection.
14   Q    Was this -- well, Doctor, you used the
15   term "sick."  Did this patient -- was this
16   patient sick?
17   A    No, sir.
18   Q    Well, prior to 12:45 on the 26th,
19   Doctor, this patient had evidenced the
20   following at times.
21             MR. JEFFERS:   Are we at 0045?
22             MR. JACOBSON:  Yes.
23   BY MR. JACOBSON:
24   Q    At times shaking, shivering,
25   grogginess, blurry vision, paleness,
0102
 1   rectal/vaginal pressure, restlessness and
 2   anxiety.
 3   A    Yes, sir.
 4   Q    Do you agree -- do you agree with all
 5   that, Doctor?
 6   A    That was described, yes, sir.
 7             MR. JEFFERS:   That wasn't the
 8   question.  His question was, he had --
 9             MR. JACOBSON:  All right.  So --
10   so --
11             MR. JEFFERS:   I want the question
12   read back.  That's not what the question
13   was.  The question inferred signs of
14   infection, and then he named those things,
15   is how I heard your question.  Well, let me
16   have the question back.  I want to make sure
17   the record is straight.
18             (At this time the question was
19   read back.)
20             MR. JEFFERS:   Okay.
21             MR. SCHOBERT:  What was time time?
22   I'm sorry.
23             MR. JEFFERS:   0045.  He said
24   12:45. I withdraw, sorry.
25    BY MR. JACOBSON:
0103
 1   Q    Okay.  Now, is that a patient, Doctor,
 2   who is sick as you used the term?
 3   A    No, sir.  She is not.
 4   Q    Okay.  Fair enough.  Doctor, at 8:20
 5   p.m., Dr. Hahn indicates that he ordered a
 6   urinalysis along with a culture and
 7   sensitivity of the urine.
 8             MR. JEFFERS:   Objection.  You
 9   mean he -- in his deposition?
10             MR. JACOBSON:   Yes.
11             MR. JEFFERS:   Okay.  Go ahead.
12   BY MR. JACOBSON:
13   Q    He did indicate that in his deposition,
14   correct, Doctor?
15   A    He indicated that in his deposition.
16   Q    Okay.  Now, Doctor, when you order a
17   culture and sensitivity from the urine --
18   pardon me; a culture and sensitivity and
19   urinalysis for a patient, do you do that
20   when you have a reasonable suspicion of
21   infection?
22   A    I may.
23   Q    Okay.  Well, that would be the primary
24   reason you'd order a culture and sensitivity
25   on a patient's urine, because you --
0104
 1   correct, Doctor, because you  --
 2   A    A culture and sensitivity, yes, sir.
 3   Q    Okay.  The primary reason that you
 4   order a culture and sensitivity from a
 5   patient's urine is because you have a
 6   reasonable suspicion of infection, correct?
 7   A    I have some suspicion.
 8   Q    Okay.  Now, the fact that Dr. Hahn has
 9   testified that he ordered a culture and
10   sensitivity and a urinalysis at 8:20 p.m. on
11   the 25th, Doctor, does that suggest to you
12   that, indeed, he had a reasonable degree of
13   suspicion for infection at the time?
14             MR. JEFFERS:   Objection.
15             THE WITNESS:   No.
16             MR. KADLEC:    Objection.
17   BY MR. JACOBSON:
18   Q    Why not, Doctor?
19   A    Just he wanted a urine culture.
20   Q    Can we agree, Doctor, that most
21   physicians, when they order a urine culture,
22   do it because they have a reasonable
23   suspicion of infection?
24   A    They might, yes.
25   Q    Well, is that your understanding,
0105
 1   Doctor, of the reason why most, if not all,
 2   physicians order a urine culture, because
 3   they have a reasonable suspicion of
 4   infection?
 5   A    No, sir.
 6   Q    Okay.  Why else do they do it?
 7   A    In -- in pregnant women, we do it
 8   routinely, suspicious of infection or not.
 9   Q    Well, how about in patients who aren't
10   pregnant?
11   A    No, we don't do it then, but in
12   pregnant women on their first prenatal visit
13   we do it.
14   Q    Okay.  So, there's nothing routine
15   about his ordering a culture and sensitivity
16   on this patient, correct?
17   A    He ordered it in response to the
18   communication with the nurses.
19   Q    Okay, but it's not a routine thing.  He
20   did it because, presumably, he was concerned
21   about infection, correct?
22             MR. JEFFERS:   Objection.
23             MR. SCHOBERT:  Objection.
24   BY MR. JACOBSON:
25   Q    Is that your answer, Doctor?
0106
 1             MR. JEFFERS:   How can you assume
 2   that?
 3             THE WITNESS:   He ordered it.
 4   BY MR. JACOBSON:
 5   Q    Okay.  Can you think of any other good
 6   reason why he would order a culture and
 7   sensitivity of the urine other than that he
 8   was concerned about infection?
 9   A    He ordered a culture and sensitivity.
10   Q    That's not -- that's not responsive,
11   Doctor, with all due respect.
12             MR. JEFFERS:   He wants to know if
13   you can think of some other reason other
14   than infection.
15   BY MR. JACOBSON:
16   Q    Yeah.
17   A    No, that's the probable reason.
18   Q    Okay.  Now, if we work on the premise
19   that Dr. Hahn has a reasonable suspicion of
20   infection at 8:20 -- well, strike that.
21   But, Doctor, you have -- let me strike that
22   question.
23             You have no reasonable suspicion
24   of infection on this patient at 8:20,
25   correct?
0107
 1   A    That's correct.
 2   Q    Okay.  So, that's another area where
 3   you appear to disagree with Dr. Hahn.
 4             MR. KADLEC:   Objection.
 5             MR. JEFFERS:   Objection.  That's
 6   argumentative.  You don't even have to
 7   answer that.
 8   BY MR. JACOBSON:
 9   Q    I'm not going to push it.
10             Doctor, at 12:30 a.m. on the
11   26th, this patient had a pulse of 128,
12   correct?
13   A    Yes, sir.
14   Q    That tachycardia would be outside the
15   range of normal even for a postpartum
16   patient, correct?  Correct, Doctor?
17   A    I previously stated this morning that
18   120 was what I would consider up to normal.
19   So, 128 by my own definition would be
20   elevated.
21   Q    Okay.  Did Nurse Prokop have a duty to
22   tell Dr. Hahn about the elevated pulse?
23   A    No, sir.
24   Q    And why not?
25   A    Because I don't think a nurse should
0108
 1   call a doctor over an elevated pulse every
 2   time they get one.  They would be on the
 3   phone 24 hours a day.
 4   Q    When she talked to Dr. Hahn 15 minutes
 5   later and reported the patient's condition,
 6   should she have included the last pulse rate
 7   which was 128 and abnormal?
 8   A    Maybe, maybe not.
 9   Q    Did she have a duty when she made that
10   call in reporting the rest of the
11   information to tell Dr. Hahn about the
12   elevated pulse rate?
13   A    I don't think we're going to decide
14   whether or not she told him or not.
15   Q    Okay, but what I want to know, Doctor,
16   not whether she told him or not; I want to
17   know whether she had a duty to tell him.
18   A    What time was this?
19   Q    When she called him and talked to him
20   at 12:45 a.m. and reported the lab values to
21   him, did she have a duty to report -- report
22   to him an abnormal pulse rate?
23   A    I think she -- she did what she had a
24   duty to do, which was report on the
25   patient's condition.
0109
 1   Q    Okay, and did that duty include
 2   reporting the abnormalities in the patient's
 3   vital signs?
 4   A    It can.
 5   Q    Did it in this case?  Did she have a
 6   duty to report the pulse rate?
 7   A    No, I don't think so.
 8   Q    Okay.  All right, so, Doctor, when you
 9   have a patient who's in the hospital, and
10   the nurse is caring for the patient, and
11   you're called at 12:45 a.m. with the status
12   report on the patient, and the nurse omits
13   to tell you an abnormal pulse rate, that's
14   nothing that would bother you?
15   A    More likely than not, that's correct.
16   Q    Okay, and that's because, Doctor, you
17   feel that the nurse is sufficiently
18   competent to determine whether or not the
19   abnormal pulse rate is a matter of concern,
20   correct?
21   A    Yes.
22   Q    Okay.  So, at least in that regard, you
23   rely on the nurse to make that decision of
24   her own discretion, correct?
25   A    Yes.
0110
 1   Q    Okay.  Doctor, in the labs that came
 2   back at 12:45 a.m., how would you --
 3             MR. JEFFERS:   Wait, wait, wait.
 4             MR. JACOBSON:  Well, the labs
 5   that were reported, the 11 -- the 11:00
 6   labs, pardon me, 11 --
 7             MR. JEFFERS:   2330.
 8   BY MR. JACOBSON:
 9   Q    Yeah, the 11:30 labs, Doctor.
10   A    Yes, sir.
11   Q    How would you characterize the degree
12   of bandemia there:  mild, moderate, severe?
13   A    It's reported as 52 percent.
14   Q    And is that a mild degree of bandemia,
15   moderate or severe, Doctor?
16   A    I would put it as moderate.
17   Q    Moderate to severe, Doctor?
18   A    Moderate.
19   Q    What would be severe?
20   A    More than that.
21   Q    Fifty-three?
22   A    No.
23   Q    Sixty?
24   A    Sixty.
25   Q    And how would you characterize the
0111
 1   degree of left shift, Doctor:  mild,
 2   moderate or severe?
 3   A    Moderate.
 4   Q    What would -- strike that.
 5             Doctor, do you have any -- do you
 6   have any -- strike that, strike that.
 7             Do you utilize an infectious
 8   disease text from time to time?
 9   A    Yes, from time to time.
10   Q    Which one do you use primarily?
11   A    I don't have one in my -- in my office
12   or in my library at home.
13   Q    Well --
14   A    You mean a general medical infectious
15   disease text?
16   Q    Yes.
17   A    I don't own one.
18   Q    Well, when you do utilize one from time
19   to time, which one is it?
20   A    I go down to the library, and go
21   through the various books.
22   Q    And what's the one that you head to
23   first?
24   A    I don't have one in particular in mind.
25   Q    Do you use Mandel & Bennett from time
0112
 1   to time?
 2   A    Heard of it.
 3   Q    Do you use it from time to time?
 4   A    I've looked at it.
 5   Q    Okay.  So, you do use it from time to
 6   time?
 7   A    From time to time.
 8   Q    Okay.  Doctor, to -- to what do you
 9   attribute the moderate bandemia and left
10   shift?
11   A    In this particular patient?
12   Q    Please.
13   A    The postpartum period.
14   Q    And to do -- to what do you attribute
15   the drop in white blood count?
16   A    Changes in her hemodynamic status and
17   being postpartum.
18   Q    Specifically, Doctor, what would cause
19   that -- a drop of that degree in a six and a
20   half hour period?
21   A    Changes in her hydration status.  She
22   was a preeclamptic patient who was given a
23   lot of fluids during labor and delivery.
24   Her volume was expanded, and one would
25   expect that with the labor and delivery
0113
 1   process, you could see a drop in the white
 2   count as being perfectly normal.
 3   Q    I guess I need to understand, Doctor,
 4   at the molecular and cellular level what's
 5   happening --
 6   A    Okay.
 7   Q    -- that can cause the bands to drop
 8   like that.  In the absence of infection --
 9   pardon me, that would cause the white blood
10   count to drop like that in the absence of
11   infection.  So, explain to me that, if you
12   would.  Okay.
13   A    I'm sorry?
14   Q    What -- what fluids are we talking
15   about, Doctor?
16   A    She was receiving IV fluids.
17   Q    Okay, and when did she start getting IV
18   fluids?
19   A    Right after she was admitted to the
20   hospital.
21   Q    Okay.  So, she's been on IVs
22   continuously since she -- she walked in the
23   door, correct?
24   A    Do you want me to look up when her IV
25   was started or --
0114
 1   Q    Well, we -- we -- we have a general
 2   idea, Doctor, you and I, that she's been on
 3   IV constantly for over 24 hours at this
 4   point, correct?
 5   A    Yes.
 6   Q    All right.  Now, what are the IVs doing
 7   now?  What are these fluids doing now that
 8   are causing her white blood count to drop?
 9   A    They're expanding her plasma volume.
10   Q    Okay, and how does that cause a drop in
11   the white blood count?
12   A    It dilutes it, essentially.
13   Q    Okay, and why didn't it dilute it,
14   Doctor, at 5:00 p.m.?
15   A    Because she was -- she was closer to
16   the time of her delivery.
17   Q    Now, Doctor, would the dilution of the
18   plasma volume cause a corresponding drop in
19   the immature white blood cells?
20   A    It may.
21   Q    Typically, Doctor, typically?
22   A    It may or may not.
23   Q    Doctor, in the absence of infection --
24   A    Uh-huh.
25   Q    -- if you have a situation where fluid
0115
 1   is diluting the blood volume causing a
 2   corresponding drop in the white blood count,
 3   wouldn't you expect it to cause a
 4   corresponding drop, in most cases, in the --
 5   in the count of immature white blood cells?
 6   A    Not in a postpartum patient.
 7   Q    And why is that?
 8   A    Because she tends to put out a lot of
 9   more immature forms during the course of
10   labor and delivery.
11   Q    And -- and be that as it may, Doctor,
12   when the blood volume is diluted, won't the
13   number of immature forms go down in -- in a
14   count?
15   A    As I said, it may or may not.
16   Q    Typically, Doctor, it will, correct?
17   A    I won't accept that, no.
18   Q    Fifty-one percent of the time?
19   A    No.
20   Q    More than half of the time?
21   A    I'm not saying you can predict anything
22   by it.
23   Q    What is your usual experience, Doctor?
24   A    You can't predict anything from those
25   counts and the way they change.
0116
 1   Q    If Dr. Hahn indicated in his testimony
 2   that this extent of a left shift at 11:30
 3   p.m. is beyond the normal range in the
 4   postpartum period, would you disagree with
 5   that, Doctor?
 6             MR. SCHOBERT:   Objection.
 7             THE WITNESS:   I would disagree
 8   with that.
 9   BY MR. JACOBSON:
10   Q    I just want to make sure I understand,
11   Doctor.  In the absence of infection when a
12   -- when a mother delivers vaginally, the
13   body will put out whites and immature whites
14   as an inflammatory response, correct?
15   A    The body produces white cells in
16   immature forms, yes, sir.
17   Q    Okay, in response to an inflammatory
18   process in the body, correct?
19   A    I'm not sure I would use inflammatory
20   as a descriptive term in this; in response
21   to the laboring process and the various
22   physiologic changes during the laboring
23   process.
24   Q    All right.  What are the physiologic
25   changes during the laboring process that are
0117
 1   -- that are causing the production of whites
 2   and immature whites?
 3   A    Well, sir, that would take an hour.  Do
 4   you want to do that?
 5   Q    All right, let me just backtrack, then.
 6   When the body is producing whites and
 7   immature whites in response to this process
 8   --
 9   A    Yes, sir.
10   Q    -- of labor --
11   A    Yes.
12   Q    -- does there tend to be some
13   correlation between the white counts and the
14   count of immature whites?
15   A    I don't accept any.
16   Q    What about the literature, Doctor?
17   What does -- what does it say in that regard?
18   A    I don't know at the moment.
19   Q    Okay.  Is it unusual, Doctor, for the
20   white counts to drop abruptly and the
21   immature whites to rise abruptly?
22   A    I don't think that's unusual, no.
23   Q    Is that something, Doctor, that is a
24   hallmark of infection?
25   A    No, sir, I don't accept that.
0118
 1   Q    Okay.  Now, let's go back, then,
 2   Doctor, to when we have a reasonable
 3   suspicion of infection in this patient,
 4   okay?
 5   A    Yes, sir.
 6   Q    Let me just throw out a few things.  We
 7   can agree that, prior to 12:45 a.m. on the
 8   26th, we have a patient who has at times
 9   exhibited shaking, shivering, grogginess,
10   blurred vision, paleness, rectal/vaginal
11   pressure, restlessness and anxiety, correct?
12   A    Those are all things described by the
13   nursing staff.
14   Q    Okay.  We have a patient who has had an
15   elevated temperature of 101.6, correct?
16   A    On one occasion, yes.
17   Q    Okay, and a temperature which remained
18   elevated despite anti-pyretics, correct?
19   A    I'm sorry.  It didn't remain at that
20   point.
21   Q    Okay, well, it went to 100.4, correct?
22   A    It did not remain at 101.
23   Q    But it remained elevated, Doctor,
24   despite anti-pyretics, correct?
25             MR. SCHOBERT:  Objection
0119
 1             MR. JEFFERS:   Objection. Outside
 2   --
 3   BY MR. JACOBSON:
 4   Q    All right.  Did it remain elevated?
 5   A    Her temperature came down.
 6   Q    But remained elevated?
 7   A    Yes.
 8   Q    All right, and this patient was on
 9   anti-pyretics, correct?
10   A    The patient had received Tylenol.
11   Q    Okay.  This was a patient, as we
12   discussed, who had some, in my terminology,
13   risk factors and, in your terminology,
14   issues which may play a role in acquiring
15   infection, correct?
16             MR. SCHOBERT:   Objection.
17             MR. JEFFERS:   Objection.
18             MR. JEFFERS:   Tape is out.
19   Coming out.  So we're taking a break, I take
20   it, for a few moments.
21             (At this time a short recess was
22   had.)
23   BY MR. JACOBSON:
24   Q    Doctor, there were labs -- strike that.
25   Amongst the labs -- labs that were
0120
 1   collected at 11:30 p.m. on the 25th, the
 2   labs that were reported were the SGOT and
 3   SGPT; is that correct?
 4   A    Let me check that.  This is on the 25th
 5   at 11:00; is that right?
 6   Q    Yeah, 11:30, yeah.
 7             MR. JEFFERS:   What are we looking
 8   for now?
 9   BY MR. JACOBSON:
10   Q    SGOT, SGPT.  I can find it for you,
11   Doctor.  Let me ask you this.  Why -- why
12   would one order liver enzymes at 11:30 p.m.
13   on the 25th?  What would be the purpose in
14   doing that?
15   A    To assess the patient for signs of
16   preeclampsia or eclampsia.
17   Q    Okay.
18             MR. SCHOBERT:  I'm sorry.  What
19   was the question?  I apologize.
20             MR. JACOBSON:  Why would -- why
21   would one order liver enzymes at 11:30?
22             MR. SCHOBERT:  Okay, all right,
23   thanks.
24   BY MR. JACOBSON:
25   Q    And how would the eclampsia or
0121
 1   preeclampsia affect the liver potentially 12
 2   hours after delivery?
 3   A    How could it affect the liver?
 4   Q    Yeah.
 5   A    There is a widely and well known
 6   syndrome of affecting the liver with
 7   preeclampsia, the eclampsia syndrome in
 8   which the liver enzymes are elevated,
 9   platelets are decreased.  It's called HELLP
10   syndrome, and there are various less severe
11   forms of that.
12   Q    How does one treat HELLP syndrome?
13   A    Magnesium sulfate in delivery.
14   Q    And how about in the postpartum period?
15   A    Magnesium sulfate.
16   Q    At 11:30, the -- the labs that were
17   drawn at 11:30, it appears that the SGOT is
18   56.  Is that high, Doctor?
19             MR. JEFFERS:   What was it now,
20   56?
21             MR. JACOBSON:   Yeah.
22             THE WITNESS:   Um --
23   BY MR. JACOBSON:
24   Q    Doctor, I can just read you the values
25   if you can't find it.
0122
 1   A    It depends on the range of normal for
 2   the lab.
 3   Q    Okay.  I can get that for you.
 4             MR. JEFFERS:   Is there a page
 5   that you're referring to in the compilation?
 6             THE WITNESS:   Yours is missing.
 7             MR. JEFFERS:   I know, but this is
 8   what I was given by them.  So, I can go to
 9   this.
10             MR. PARIS:     Bates stamp 45, and
11   you'll find it.
12             MR. JEFFERS:   What?
13             MR. PARIS:      Look at Bates
14   stamp 45.
15             MR. JEFFERS:   Okay.  I didn't
16   bring that one in, because you've been using
17   this little one.
18             THE WITNESS:   There it is.
19   Fifty-six was the number, yes, sir.
20   BY MR. JACOBSON:
21   Q    And the range of normal is zero to 31?
22   A    That's what's reported from the
23   laboratory, yes.
24   Q    All right, and would that be of
25   concern, Doctor?
0123
 1   A    It might be.
 2   Q    Okay.  Well, in this patient?
 3   A    It could be significant.
 4   Q    Okay, and that could be indicative of
 5   -- of HELLP syndrome, correct?
 6   A    It might be, yes.
 7   Q    It also could be indicative of
 8   infection, correct?
 9   A    No, sir.
10   Q    Why not?
11   A    It's indicative of HELLP syndrome
12   potentially evolving.
13   Q    However, Doctor, in patients who have
14   sepsis, one will often see a -- a
15   corresponding rise in liver enzymes, correct?
16   A    In sepsis, that can occur, yes, sir.
17   Q    Okay.  Retrospectively, Doctor, do you
18   have an opinion as to why the liver enzymes
19   were elevated to 56?
20             MR. JEFFERS:   Objection.  Go
21   ahead.
22   BY MR. JACOBSON:
23   Q    The SGOT was 56.
24   A    It could have been either.
25   Q    Okay.  What was it probably, Doctor?
0124
 1   A    Pre-eclampsia.
 2   Q    Doctor, why -- strike -- strike that.
 3   Doctor, the effects of preeclampsia,
 4   maternal effects of preeclampsia tend to be
 5   relieved once -- for the most part once
 6   delivery is effectuated, correct?
 7   A    Over a period of time, yes.
 8   Q    Now, why, then, Doctor, would -- what
 9   explanation would you have for the SGOT
10   being 34 at 11:23 on the 24th when the mom
11   was still pregnant and laboring, and 56 12
12   hours after delivery, actually 13 and a half
13   hours after delivery?
14   A    As I said, I think it was due to her
15   preeclampsia toxemia syndrome.
16   Q    Well, if it was due to preeclampsia
17   toxemia, wouldn't you expect the liver
18   enzymes to have been elevated prior to
19   delivery as well?
20   A    Not necessarily.
21   Q    But generally, Doctor.
22   A    No, sir.  You can't say that "generally."
23   Q    More often than not?
24   A    No, sir.
25             MR. JEFFERS:     Come on in,
0125
 1   Harley.
 2             MR. PARIS:     Harley, we're on
 3   tape.
 4   BY MR. JACOBSON:
 5   Q    All right.  At 5:30 a.m. on the 26th,
 6   the SGOT was 67.
 7             MR. JEFFERS:   I'm sorry.  When
 8   Harley opened the door and closed, I didn't
 9   hear it.
10   BY MR. JACOBSON:
11   Q    At 5:30 a.m., the SGOT was 67.
12   A    Yes, sir.
13   Q    Doctor, preeclampsia or sepsis?
14   A    Sepsis.
15   Q    Okay.  So, it's your opinion that the
16   SGOT of 56 at 11:30 p.m. on the 25th was due
17   to preeclampsia, probably, and the SGOT of
18   67 at 5:30 a.m. on the 26th was due to
19   sepsis, correct?
20   A    Yes.
21   Q    All right.  Doctor, in the reasonable
22   physician, should an SGOT of 56 in a patient
23   such as this at 11:30 p.m. on the 25th raise
24   one's level of index of suspicion for
25   infection?
0126
 1   A    No, sir.
 2   Q    And why is that?
 3   A    Because a reasonably practicing
 4   physician in a woman with preeclampsia
 5   admitted for induction of labor,
 6   subsequently delivered on magnesium sulfate,
 7   that would be a perfectly reasonable
 8   expectation that she would have an elevation
 9   of this magnitude to that point.
10   Q    Doctor, how does preeclampsia tend to
11   cause elevation of the liver enzymes?
12   A    It's thought to be due to liver
13   congestion, congestion in the portal and in
14   the liver venous system; subsequently there
15   is some cellular breakdown and release of
16   those enzymes into the circulation.
17   Q    How does magnesium sulfate tend to
18   assist the liver not -- strike that.  How
19   does magnesium sulfate tend to assist the
20   body in fighting off that process?
21   A    We don't know that answer.
22   Q    But it does, though, correct?
23   A    It has been a useful therapy for many,
24   many years in this condition.
25   Q    In other words, in a patient who's
0127
 1   getting magnesium sulfate, one would hope
 2   and expect that liver enzymes would not be
 3   elevated, correct?
 4   A    But they might go up postpartum.
 5   Q    Doctor, where in the time continuum
 6   between 11:30 p.m. on the 25th and 5:30 a.m.
 7   on the 26th did the elevation in the liver
 8   enzymes cease to be caused by preeclampsia
 9   and begin to be caused by sepsis?
10   A    I don't think I understand your
11   question.
12   Q    Well, it's your testimony here, Doctor,
13   that the -- that the elevation in the SGOT
14   at 11:30 p.m. on the 25th was due to
15   preeclampsia.
16   A    Yes, sir.
17   Q    And that at 5:30 a.m. on the 26th it
18   was due to sepsis.
19   A    Yes, sir.
20   Q    Now, where in that time continuum, six
21   hours, Doctor, did the -- did the
22   preeclampsia -- did -- did the liver enzymes
23   elevation -- strike that.
24             Where -- where between 11:30 p.m.
25   and 5:30 a.m. did the preeclampsia leave off
0128
 1   and the sepsis pick up?
 2   A    I don't know.
 3   Q    Okay.  Somewhere in the middle of that
 4   range, Doctor?
 5   A    Possibly.
 6   Q    Okay.  Well, Doctor, you wouldn't
 7   expect that sepsis would elevate the SGOT in
 8   a matter of minutes; would it?
 9             MR. JEFFERS:   Would you -- would
10   you say that again?
11   BY MR. JACOBSON:
12   Q    Would the SGOT cause elevation of liver
13   enzymes in -- in a matter of minutes?
14   A    Minutes?
15   Q    Yeah.
16   A    You mean less than ten?
17   Q    Yeah.
18   A    I wouldn't expect that, no.
19   Q    Less than an hour?
20   A    I wouldn't expect that.
21   Q    Less than two hours?
22   A    Somewhere in the hours range, we're
23   going to get to the point where it would.
24   Q    Okay.  Doctor, is 67 a severe elevation
25   in the SGOT?
0129
 1   A    Not really.
 2   Q    Moderate to severe?
 3   A    Mild.
 4   Q    Doctor, the sepsis in this patient
 5   probably began somewhere hours before 5:30,
 6   correct, in the hour range before 5:30,
 7   correct?
 8   A    I'm not sure I accept that.
 9   Q    Well, Doctor, you've just told me that
10   it takes in the range of hours for sepsis to
11   cause an elevation of SGOT, and she's got it
12   at 5:30 a.m., correct?
13   A    Okay.
14   Q    So, working backwards, we know that it
15   was hours before 5:30 a.m. that she was
16   septic, correct?
17             MR. JEFFERS:   Objection.  Go
18   ahead.
19             THE WITNESS:   I will not use -- I
20   will not accept the term, septic.
21   BY MR. JACOBSON:
22   Q    Well, you -- you -- Doctor -- all
23   right, it was hours before 5:30 a.m. that
24   sepsis was causing the elevation of the
25   liver enzymes, correct?
0130
 1   A    Retrospectively.
 2   Q    That is correct?
 3   A    That is correct.
 4   Q    All right.  Now, she also had blood
 5   pressure readings that were low after
 6   midnight, between midnight and 5:30 a.m. on
 7   the 26th, correct?
 8   A    Yes, sir.
 9   Q    Retrospectively, Doctor, was sepsis
10   causing that as well?
11   A    More likely than not, yes.
12   Q    Okay.  Doctor --
13             MR. JEFFERS:   I want to put on
14   the record just a general objection to the
15   retrospective theory of the case in the
16   sense that that doesn't go to either
17   standard -- should not go to standard of
18   care or to causal relationship.
19   BY MR. JACOBSON:
20   Q    Doctor, more likely than not, was
21   sepsis causing an elevation of her heart
22   rate to 128?
23   A    At what time?
24   Q    At 11:30 -- strike that.  At 12:30 p.m.
25   on the 26th.
0131
 1             MR. JEFFERS:   12:30 --
 2   BY MR. JACOBSON:
 3   Q    P.M. on the -- a.m. on the 26th.
 4             MR. JEFFERS:   Yeah.
 5             MR. SCHOBERT:  This is again
 6   retrospectively, Bill?
 7             MR. JACOBSON:   Yes.
 8             MR. SCHOBERT:  Okay.
 9             MR. JACOBSON:  Yes.
10             THE WITNESS:   More likely than
11   not, yes.
12   BY MR. JACOBSON:
13   Q    Doctor, her fever at 7:30 p.m. on the
14   25th of 101.6, retrospectively, was that
15   probably being caused, Doctor, by a
16   bacteremia?
17   A    No, no, sir.
18   Q    Doctor, her decreased urine output
19   before midnight on the 26th, was that
20   probably due to infection, bacteremia or
21   sepsis?
22   A    No, sir.
23   Q    Okay.  To what do you attribute it?
24   A    I attribute it to her fluid management,
25   her preeclampsia, her postpartum condition.
0132
 1   Q    Doctor, her normal white count and left
 2   -- pardon me.  The drop in the white count
 3   that is seen on the 11:30 labs and the left
 4   shift which you described as moderate, in
 5   retrospect, Doctor, was that probably being
 6   caused by sepsis or infection?
 7             MR. SCHOBERT:  Objection.
 8             THE WITNESS:   No, I don't accept
 9   that.
10   BY MR. JACOBSON:
11   Q    How about her labs at -- at 5:30 a.m.,
12   Doctor?
13             MR. JEFFERS:   At five -- okay.
14   BY MR. JACOBSON:
15   Q    How would you characterize the left
16   shift there, Doctor?
17             MR. JEFFERS:   Retrospectively?
18   BY MR. JACOBSON:
19   Q    No.  How would you characterize the
20   left shift?
21   A    The left shift?
22   Q    Yeah.
23   A    Mild.
24   Q    Okay, and the degree of bandemia?
25   A    Fifteen percent.
0133
 1   Q    And your -- and your characterization,
 2   Doctor?
 3   A    That's -- that's mild.
 4   Q    Was that probably being caused by
 5   sepsis at that point, Doctor?
 6             MR. JEFFERS:   Objection.
 7   Retrospectively?
 8             MR. JACOBSON:   Yeah.
 9             THE WITNESS:   Retrospectively?
10   BY MR. JACOBSON:
11   Q    Yeah.
12   A    Not yet.
13   Q    Doctor, the 11:30 labs --
14   A    Yes, sir.
15   Q    Go back to that.
16             MR. SCHOBERT:  On the 25th?
17   BY MR. JACOBSON:
18   Q    On the 25th.
19             MR. JEFFERS:   On the what?
20             MR. PARIS:     25th.
21             MR. JEFFERS:   25th.
22   BY MR. JACOBSON:
23   Q    Okay.  The metamyelocytes, Doctor, am I
24   pronouncing that correctly?
25   A    Yes, sir.
0134
 1   Q    All right, of six.
 2   A    Yes, sir.
 3   Q    Is that normal?
 4   A    I don't view it as abnormal.
 5   Q    What -- what's the normal range of
 6   metamyelocytes, Doctor?
 7   A    It depends on the laboratory.
 8   Q    Okay.  Typically in a patient, you will
 9   see none, correct?
10   A    Typically in a patient who is having a
11   blood count drawn, you will see none.
12   Q    Six would be unusual, correct?
13   A    In the postpartum patient, not
14   necessarily.
15   Q    Doctor, to what do you attribute the
16   metamyelocytes retrospectively?
17   A    To her delivery.
18   Q    All right, Doctor.  At 12:45, we have a
19   patient who has --
20             MR. JEFFERS:   12:45 a.m.
21             MR. JACOBSON:  12:45 a.m.
22             THE WITNESS:   Okay.
23   BY MR. JACOBSON:
24   Q    Who has -- we -- ultimately, Doctor,
25   I'm going to run through some of this
0135
 1   patient's picture up to 12:45 a.m. on the
 2   26th, and ask you if that patient's picture,
 3   meaning clinical presentation, labs, okay?
 4   A    Yes, sir.
 5   Q    And ask you if you believe that there
 6   is a reasonable suspicion of infection,
 7   okay?  This patient, we have agreed,
 8   exhibited at times shaking, shivering,
 9   grogginess, blurry vision, paleness,
10   rectal/vaginal pressure, restlessness and
11   anxiety.  We have agreed that this patient
12   had an elevated temperature of 101.6 and a
13   later temperature which remained elevated of
14   100.4.  We have agreed, Doctor, that this
15   patient had a vaginal delivery.  We have
16   agreed, Doctor, that this patient had had a
17   decrease in her urine output, that this
18   patient had had anxiety -- anxiety and
19   restlessness, that this patient had had an
20   elevated pulse of 128.  We have agreed that
21   at 12:45 a.m. -- pardon me, the 11:30 p.m.
22   labs on the 25th exhibited a drop in the
23   white blood count and moderate left shift
24   and bandemia, correct?  Is that all correct?
25   A    You're making the statement and reading
0136
 1   things.
 2   Q    Have we agreed to all of that, Doctor?
 3   A    I'm not sure I've agreed to all of
 4   that, no.
 5             MR. SCHOBERT:  Objection.
 6             MR. JACOBSON:  Well, read it
 7   back, and you can tell me what you haven't
 8   agreed to.
 9             MR. SCHOBERT:   Objection.
10             MR. JEFFERS:   I don't know how
11   she can read it back without taking each
12   item by you.
13   BY MR. JACOBSON:
14   Q    Well, you can tell me what -- what you
15   don't agree with.
16   A    All right. You gave a laundry list of
17   all the things that were observed in this
18   patient.
19   Q    All right.
20   A    Most of that is true.  That is correct.
21   Q    Well, is there anything that I've said
22   that -- that isn't true in that lottery --
23   in that laundry list?
24   A    No, you've given us a very extensive
25   laundry list of the things that were
0137
 1   observed in this patient.
 2   Q    And we also know that this patient had
 3   an elevated SGOT and SGPT, correct?
 4   A    That was noted, yes.
 5   Q    The labs that were drawn at 11:30,
 6   correct?
 7   A    Yes, sir.
 8   Q    Now, in a patient with all those
 9   things, Doctor, when Dr. Hahn is called at
10   12:45, is there a reasonable suspicion of
11   infection?
12   A    No, sir.
13   Q    Okay.  Doctor, at 12:45, is infection
14   in your differential for this patient?
15   A    No, sir.
16   Q    And why is that?
17   A    She doesn't have any sign of infection.
18   Q    What are signs of infection?
19   A    Different than what this patient has.
20   Q    Can you give me, Doctor, what you're
21   looking for?
22   A    Consistently elevated fever,
23   consistently elevated white count.  There's
24   a whole laundry list of things that you
25   acquire during your course and training.
0138
 1   Q    Please, give me that laundry list,
 2   Doctor.
 3   A    As I said, it's not in this patient.
 4   She had no consistent and compelling signs
 5   of infection.
 6   Q    Well, you've given me two in your
 7   laundry list:  consistently elevated fever,
 8   consistently elevated white count.  I want
 9   to know what else is in that list, Doctor.
10   A    In a patient during her prenatal
11   course, she had no particular risk factors.
12   She had a Group B -- Group B strep negative
13   culture.  During her prenatal course, her
14   labor and delivery was quite uneventful, in
15   our terms.  She did not have prolonged
16   ruptured membranes.  She did not have an
17   excess number of vaginal exams.  She had one
18   elevated temperature in the first 24 hours.
19   She had restlessness, which is not unusual
20   in the postpartum patient.  She had a white
21   count which was changing and variable, which
22   is not unusual in the postpartum patient.
23   She had some anxiety, which is not unusual
24   in the postpartum patient.  She also was
25   administered magnesium sulfate which has
0139
 1   many effects on the postpartum patient
 2   including the blurry vision and some of the
 3   mental changes that is seen.  There was no
 4   evidence in this patient at any time up to
 5   the time that you have quoted that there was
 6   any signs of infection, and it would not be
 7   included in the differential of a reasonable
 8   and prudent physician or among nurses.
 9   Q    Doctor, you used the term, risk
10   factors.  So, that is something that you do
11   look for, risk factors for infection,
12   correct?
13   A    I was using your word for you.
14   Q    Doctor, the fact of the matter is that
15   one thing you -- you do when you're trying
16   to evaluate the potential infection is
17   looking for risk factors, correct?
18   A    We look for --
19   Q    Is that correct, Doctor?  You look for
20   risk factors for infection?
21   A    We look for things that may have played
22   a role in infection acquisition, yes.
23   Q    Okay, and those things are called risk
24   factors, correct?
25   A    You used that term.
0140
 1   Q    Well, you used it too.
 2   A    I was using it for you.
 3   Q    Now, Doctor, what you've done here just
 4   now is recapitulated what we've gone over,
 5   but once again, what I want to know is what
 6   you're looking for that isn't in this
 7   patient, okay?  Now, you've mentioned two
 8   things.  You've mentioned a prolonged
 9   elevation of fever and something else.  I
10   don't even remember.
11             MR. PARIS:     Elevated white
12   blood count.
13   BY MR. JACOBSON:
14   Q    Elevated white blood count, okay.  What
15   else do you look for as signs of infection
16   that this patient did not have?
17   A    She didn't have any signs of infection.
18   Q    Well, what are the other signs, Doctor?
19   A    You've just given me a laundry list of
20   things you think are signs of infection and,
21   in fact, they're not compelling signs of
22   infection.
23   Q    Doctor, that's not my question.  I want
24   to know what you feel are compelling signs
25   of infection.
0141
 1   A    Compelling signs of infection.
 2   Q    Elevated white blood count, fever?
 3   A    Elevated white blood count, fever,
 4   pain, redness, swelling --
 5   Q    Okay.  Go ahead.
 6   A    Continued elevation of the white count,
 7   and then we have a region of the body that
 8   will be affected.
 9   Q    Anything else, Doctor, or is that
10   pretty much it?
11   A    Well, are we talking in general or in
12   the postpartum patient?
13   Q    In the postpartum patient.
14   A    In the postpartum patient, that's in
15   general.
16   Q    Okay.  So, the five things I think you
17   mentioned are elevated temperature,
18   prolonged elevated temperature --
19   A    Yes, sir.
20   Q    -- prolonged elevation of white count,
21   pain, redness and swelling, correct?
22   A    Yes, sir.
23   Q    All right, now, Doctor, with respect to
24   pain, a patient that has rectal/vaginal
25   pressure, that could be the equivalent of
0142
 1   pain, correct?
 2   A    Yes, sir.
 3   Q    All right.  So, this -- this patient --
 4   strike that.  Now, with respect to redness
 5   and swelling, Doctor, redness and swelling,
 6   number one, number one, there's some pitting
 7   edema in this patient which you would expect
 8   with a postpartum patient, correct?
 9   A    Yes, sir.
10   Q    All right.  So, sometimes it differs --
11   no, strike that.
12             With respect to redness, Doctor,
13   you may not get redness unless you have a
14   localized infection, correct?
15   A    That's possible.
16   Q    All right, and if the infection has a
17   subcutaneous source, you may have redness
18   and not see it, correct, Doctor?
19   A    Define -- what do you mean by
20   subcutaneous; below the skin?
21   Q    Uterine infection, yeah, uterine
22   infection.
23   A    You may not see redness; that's
24   correct.
25   Q    That's the same thing with swelling,
0143
 1   correct, Doctor?
 2   A    You may not see it; that's correct.
 3   Q    But the two constants are prolonged
 4   elevated temperature and a prolonged
 5   elevated white count, correct?
 6   A    I --
 7   Q    Strike -- strike that.  Doctor, when a
 8   white count falls as it did in this patient
 9   --
10   A    Yes, sir.
11   Q    -- it -- I think it's your testimony
12   that could simply be returning to normal,
13   correct?
14   A    Yes, sir.
15   Q    Okay.  Another possibility, Doctor, in
16   general, when a white -- strike that.
17             Would you characterize --
18   characterize this drop in the white count as
19   an abrupt drop?
20   A    No, I wouldn't use that word.
21   Q    Well, when you have a drop in the white
22   count of -- of this degree, Doctor, in one's
23   differential should also be infection,
24   correct?
25             MR. JEFFERS:   I didn't follow
0144
 1   that question.
 2   BY MR. JACOBSON:
 3   Q    When you have a white blood count that
 4   drops from 16,100 to 4600 --
 5   A    In this particular patient?
 6   Q    In any patient.
 7   A    In any patient, no, sir, I will not
 8   accept that.
 9   Q    In a six-hour period.  All right, well
10   -- all right, let me put it to you this way.
11   An infection which is growing stronger in
12   which the body is losing its ability to
13   compensate --
14   A    Uh-huh.
15   Q    -- can cause a drop in the white blood
16   count, correct?
17   A    Yes, sir.
18   Q    All right.  All right, now, Doctor,
19   let's -- let's move on to the -- the pulse,
20   and we -- we discussed that.  The pulse is
21   on this patient at 2:15 a.m. of 100 over 44,
22   88 over 53 and 120 over 66.  Pardon me, the
23   blood pressures: 100 over 44, 88 over 53,
24   120 over 60, Doctor, those are low blood --
25   low blood pressures, correct?
0145
 1   A    They were inconsistent blood pressures.
 2   Q    Are they low, Doctor?
 3   A    Some of those numbers are low, yes.
 4   Q    All right.  Generally, Doctor, in a
 5   preeclamptic patient, you would expect the
 6   blood pressures to be normal or high,
 7   correct?
 8   A    Yes, sir.
 9   Q    All right.  So, these are cause for
10   concern, correct?
11   A    They may be.
12   Q    Did Nurse Prokop have a duty to
13   communicate these blood pressures to Dr.
14   Hahn?
15   A    Yes.
16   Q    If she did not do that, she deviated
17   from her duty, correct?
18   A    She did that.
19   Q    Doctor, hypothetically, if she had not
20   done that, she deviated from her duty,
21   correct?
22             MR. JEFFERS:   Objection.  Go
23   ahead.
24             THE WITNESS:   Hypothetically, but
25   she did that.
0146
 1   BY MR. JACOBSON:
 2   Q    Your answer, Doctor, is:  yes, I'm
 3   correct; hypothetically, if she didn't do
 4   that, she would be deviating, but you feel
 5   that she did do that; is that a fair
 6   statement?
 7   A    I feel she did do that, yes, sir.
 8   Q    Okay. The statement I made is a correct
 9   statement?
10   A    No, sir.  I'm saying that I think she
11   communicated with the physician.
12   Q    And if she didn't, then, she's
13   deviated, correct?
14   A    Yes.
15   Q    All right.  Doctor, should the
16   reasonable nurse be aware that a drop in
17   blood pressure can be a sign of sepsis?
18             MR. JEFFERS:   In and of itself?
19             MR. JACOBSON:  Yeah.
20             THE WITNESS:   A drop in blood
21   pressure can be a sign of anything.
22   BY MR. JACOBSON:
23   Q    Doctor, it's nonspecific?
24   A    It's nonspecific.
25   Q    But it can -- it can be a sign of
0147
 1   sepsis, correct?
 2   A    Advanced sepsis, yes.
 3   Q    By the way, Doctor, if you had a
 4   patient where you had a reasonable degree of
 5   suspicion of sepsis, and the blood pressure
 6   was dropping, would you continue the patient
 7   on mag sulfate?
 8   A    I may.
 9   Q    Doctor, would you be concerned that the
10   mag sulfate might contribute to the
11   patient's hemodynamic instability?
12   A    I might, yes.
13   Q    So, that's something that mag sulfate
14   can do, correct?
15   A    Yes, sir.
16   Q    All right.  If you have a patient,
17   Doctor, who is, in your opinion, potentially
18   going into shock, the mag sulfate would be
19   contraindicated, correct?
20   A    What do you mean by "potentially going
21   into shock"?
22   Q    If you have a patient, Doctor, where
23   the blood pressures are dropping, and you
24   have a reasonable suspicion that the patient
25   is going into shock, under those
0148
 1   circumstances, you would discontinue mag
 2   sulfate, correct?
 3   A    Yes, sir, under those circumstances.
 4   Q    Okay, and that's what a reasonable
 5   physician would do, correct?
 6   A    At some point in time, yes.
 7   Q    And the reason that the reasonable
 8   physician and yourself would do that is
 9   because the mag sulfate has the potential to
10   contribute to causing that patient to go
11   into shock, correct?
12   A    No, sir.
13   Q    Okay.  You want --
14   A    You put it better before.  Her
15   hemodynamic instability, it might contribute
16   to that.
17   Q    All right.
18   A    And we'd discontinue it.
19   Q    All right, and how physiologically,
20   Doctor, might it contribute to the
21   hemodynamic instability?
22   A    It can cause some lowering, although
23   minor, of the blood pressure.  It probably
24   alters somewhat a control of our own blood
25   pressure, both centrally, meaning within the
0149
 1   central nervous system and what controls our
 2   blood pressure, and peripherally by blocking
 3   the smooth muscle cells, and it makes them
 4   relax, and, so, it can have some effects on
 5   her blood pressure.
 6   Q    So, mag sulfate can contribute to
 7   blocking of the body's compensatory systems
 8   when the blood pressure is dropping, correct?
 9   A    It might.
10   Q    Well, that is a property which is known
11   of mag sulfate, correct?
12   A    Yes.
13   Q    All right.  Doctor, certainly, if you
14   have a patient who you're concerned may be
15   going into shock, if you have a patient who
16   you have a reasonable suspicion that the
17   patient is going into shock, would you
18   continue to give Ativan, Doctor?
19   A    It depends on the patient -- the
20   patient's condition.
21   Q    Well, the blood pressure is dropping.
22   There's sign of -- of liver and kidney
23   involvement.  Do you give Ativan?
24   A    I may or may not.
25   Q    So, you don't think that Ativan has the
0150
 1   same potential of contributing to the
 2   hemodynamic instability?
 3   A    Do you mean in general or in this case
 4   in particular --
 5   Q    In general.
 6   A    -- when Ativan was administered as a
 7   theoretical.
 8   Q    Okay.  How many times did this patient
 9   get Ativan?  Do you know?
10   A    I think two.
11   Q    Okay.  Do you know what the doses were?
12   A    One was .5, I think, and one was one
13   milligram.
14   Q    Okay.  Now, Doctor, does -- does one
15   milligram of Ativan have the potential to
16   contribute to the patient's hemodynamic
17   instability?
18   A    It might.
19   Q    Okay.  In fact, Doctor, Ativan is a
20   drug which has the express purpose of
21   depressing central nervous system function,
22   correct?
23   A    That's your statement.
24   Q    Is that true?
25   A    That has been described as one of the
0151
 1   drug's effects, yes.
 2   Q    And if a patient is going into shock,
 3   you wouldn't want to do that, correct?
 4   A    That's correct.
 5   Q    Doctor, you -- you've indicated, and
 6   let me just back up, that strep A is an
 7   aerobic bacteria, correct?
 8   A    Yes, sir.
 9   Q    As such, Doctor, does it tend to
10   produce foul smelling lochia?
11   A    It may or may not.
12   Q    Okay.  Typically, Doctor?
13   A    It may or may not.
14   Q    Okay, typically, Doctor, as a general
15   rule, aerobes will not produce a smell, a
16   foul-smelling lochia; is that -- is that a
17   fair statement?
18   A    That's a fair statement.
19   Q    All right.  Let me turn, Doctor, to the
20   -- once again to the 12:45 telephone
21   communication between Nurse Prokop --
22             MR. JEFFERS:   Do you have an
23   estimate on how long we're going to be?
24             MR. JACOBSON:   It's going to be a
25   little while.
0152
 1             MR. JEFFERS:   Well, you've got a
 2   witness apparently.
 3             MR. JACOBSON:   I understand.
 4             MR. JEFFERS:   I don't think we
 5   need on a Saturday to take her at 5:00.  I
 6   want to know what you guys want to do.
 7             MR. JACOBSON:   I've got a baby
 8   six days old.  I'm not thrilled about being
 9   here.  I'm doing what I have to do, okay?
10   BY MR. JACOBSON:
11   Q    Doctor, let's turn to the 12:45 a.m.
12   phone call.
13   A    On -- on what -- what day?
14   Q    On the 26th.
15   A    On the 26th?
16   Q    Yeah.
17   A    So that's --
18             MR. JEFFERS:   0045.
19             THE WITNESS:   0045.  Yes, sir.
20   BY MR. JACOBSON:
21   Q    Doctor, I want to ask you what a
22   reasonable physician in the position of Dr.
23   Hahn has the duty to ask about, okay.  Now,
24   first of all, does Dr. Hahn in that
25   circumstance have the duty to ask about all
0153
 1   of the labs?
 2             MR. JEFFERS:   Okay.  Let me just
 3   put a standing objection to your -- to this
 4   series of questions, and then you go ahead.
 5            THE WITNESS:   What do you mean,
 6   all --
 7             MR. KADLEC:    Objection.  I'll
 8   take a standing objection.
 9             THE WITNESS:   What do you mean,
10   all of the labs?
11   BY MR. JACOBSON:
12   Q    Well, does Dr. Hahn have the obligation
13   to say to the nurse:  read me every lab
14   result?
15   A    No.
16   Q    Does he have an obligation to say to
17   the nurse:  read me the abnormal lab results?
18   A    He may say that.
19   Q    Does he have the obligation?
20   A    I wouldn't say it's an obligation.
21   Q    Okay.  If he doesn't request that, does
22   the nurse have the obligation to read him
23   all the abnormal lab results?
24   A    I think a nurse has the obligation to
25   communicate the clinical picture.
0154
 1   Q    Including -- including --
 2   A    Normal and abnormal lab results.
 3   Q    So, if Dr. Hahn doesn't ask about the
 4   abnormal lab results, the nurse has the duty
 5   to communicate them to him, correct?
 6   A    Sometimes that can occur in clinical
 7   circumstances.
 8   Q    Doctor, what I'm asking about duty, I'm
 9   asking generally, okay?
10   A    Okay.
11   Q    As a general rule, does -- if Dr. Hahn
12   does not ask about the abnormal labs, does
13   the nurse have the duty to communicate those
14   to Dr. Hahn?
15   A    Not necessarily.
16   Q    Okay.  So, if Dr. Hahn -- all right.
17   Let's -- let's ask about specifics, okay?
18   The white blood count --
19   A    Right.
20   Q    -- does the nurse have the duty to
21   communicate that to Dr. Hahn if he doesn't
22   ask about it?
23   A    The total white count?
24   Q    Yes.
25   A    Yes.
0155
 1   Q    All right.  Does the nurse have the
 2   duty to communicate the abnormal white
 3   counts -- pardon me, the immature white
 4   blood cell counts?
 5   A    No.
 6   Q    All right.  Why not?
 7   A    Because you don't need that information
 8   most of the time.
 9   Q    What about the SGOT/SGPT?
10   A    Yes.
11   Q    Okay.  Now, the urine output at that
12   time was about 30 ccs per hour; is that
13   correct, Doctor?
14   A    Yes, sir.
15   Q    Does the nurse have a duty to
16   communicate that to him?
17   A    If she's concerned about it.
18   Q    Okay, which we know she was, correct?
19   A    She reported that to him, she says.
20   Q    All right.  So, we agree she has the
21   duty to communicate that to him, correct?
22   A    I don't think she has a duty to report
23   30 ccs an hour which I told you was normal.
24   Q    Okay.  Well, Doctor, I think your
25   statement was, if she's concerned about it,
0156
 1   she has a duty to report it, correct?
 2   A    Correct.
 3   Q    All right, and she was concerned about
 4   it, correct?
 5   A    She was concerned about it.
 6   Q    Does she have a duty to communicate any
 7   abnormal vital signs if Dr. Hahn does not
 8   ask about it?
 9   A    Yes.
10   Q    All right.  Does she have a duty to
11   communicate the fact that the patient was
12   restless?
13   A    She did report that.
14   Q    Does she have a duty to do so?
15   A    Yes, and she did it.
16   Q    Does she have a duty to report the
17   patient's anxiety?
18   A    She did do that.
19   Q    Does she have a duty to do so?
20   A    She felt she did, and she did it.
21   Q    Well, do you feel that she did?
22   A    She felt it was clinically significant
23   and reported it to the physician.
24   Q    Doctor --
25   A    So, obviously, she felt she needed to
0157
 1   do that.
 2   Q    What I'm trying to determine here,
 3   Doctor, is:  is this something that, in the
 4   exercise of ordinary care, a reasonable
 5   nurse would do, report it?
 6   A    Yes, sir, I think it is.
 7   Q    All right, all right.  The fact that
 8   the most recent temperature had been 100.4,
 9   Doctor, is that something that she had a
10   duty to communicate to Dr. Hahn?
11   A    Personally, I don't think so.
12   Q    Blood pressure, Doctor, of 119 over 65
13   and 137 over 65, do you need to communicate
14   those things?  Let me strike that.
15   A    No, sir.
16   Q    Let me strike that.  All right.  Well,
17   you say she doesn't have a duty, and why is
18   that, Doctor?
19   A    It has dropped.  It's changed.  She may
20   or may not feel like there is a duty to
21   communicate that.  There may be discussion
22   of it.  There's a whole clinical, you know,
23   circumstance here.
24   Q    You feel, Doctor, that -- that the
25   blood pressure needs -- needs to be somewhat
0158
 1   lower before she has a formal duty then to
 2   communicate it, correct?
 3   A    Correct.
 4   Q    Now, we've already discussed that with
 5   respect to the 2:15 blood pressure.  Now,
 6   Doctor, in the 3:45 a.m. telephone
 7   communication to Dr. Hahn, you've already
 8   discussed the blood pressures.  There's a
 9   complaint that the patient's abdomen is
10   feeling hard at 2:30.  Does the nurse have
11   -- strike that.  Does Dr. -- strike that.
12   In -- in the 3:45 a.m. phone call, does the
13   nurse have the duty to communicate to Dr.
14   Hahn that the -- that the patient had a
15   subjective feeling of abdomen hard at 2:30?
16   A    No, sir.
17   Q    Does the nurse have a duty to
18   communicate to Dr. Hahn the objective
19   finding of abdomen distended at 3:15 a.m.?
20   A    No, sir.
21   Q    Okay.  Does the nurse have a duty to
22   communicate to Dr. Hahn the objective
23   finding at 3:15 a.m. of diminished bowel
24   sounds?
25   A    No, sir.
0159
 1   Q    And why is that?
 2   A    Because that has no meaning at that
 3   particular time.
 4   Q    Okay.  Doctor, diminished bowel sounds
 5   are caused by the slowing or lack of
 6   peristalsis in the bowel?
 7   A    It's generally thought to be so, yes.
 8   Q    Okay. Can infection cause that?
 9   A    It can, yes.
10   Q    Does it cause that from time to time?
11   A    It didn't in this patient.
12   Q    To what do you attribute the diminished
13   bowel sounds at 3:15?
14   A    She's postpartum and getting magnesium
15   sulfate.
16   Q    Okay.  Doctor, did she have any
17   diminished bowel sounds prior to 3:15 a.m.?
18   A    I don't recall if it was noted or not.
19   Q    Okay.  Now, when the nurse examines
20   this patient, you know, in regular exams,
21   between the time of delivery and 3:15 a.m.,
22   one thing the nurse would routinely do would
23   be listen to the bowel -- to the bowel
24   sounds, correct?
25   A    No, sir.
0160
 1   Q    So, if the nurse did not listen to the
 2   bowel sounds until 3:15 a.m. for the first
 3   time, you would have no problem with that?
 4   A    That's correct.
 5   Q    Doctor, 1:00 a.m., this patient felt
 6   some uterine cramping for which Motrin was
 7   given.  Did the nurse have a duty to
 8   communicate that to Dr. Hahn?
 9   A    No, sir.
10   Q    Now, Doctor, the 5:30 a.m. labs.
11   A    Yes, sir.
12   Q    Blood pressure -- pardon me.  I -- I'm
13   sorry.  At the 7:20 a.m. phone call, there
14   was -- the most recent blood pressure
15   reading was 113 over 53 at 6:30 a.m.
16             MR. JEFFERS:   What was it?  I
17   didn't hear.
18             MR. JACOBSON:  One hundred
19   thirteen over 53
20             MR. JEFFERS:   Thank you.
21   BY MR. JACOBSON:
22   Q    Did the nurse have a duty to
23   communicate that to Dr. Hahn?
24   A    I'm sorry.  We're speaking of the
25   7:30?
0161
 1   Q    At -- at 7:20 a.m. there's a phone call
 2   to Dr. Hahn.
 3   A    Yes, sir.
 4   Q    You know, I'm going to strike that
 5   question and move on.  All right.  Let me
 6   move on, Doctor.
 7             I want to talk then about Dr.
 8   Hsieh a little bit.  First of all, Doctor,
 9   what is your understanding of the reason
10   that Dr. Hsieh was called in to see this
11   patient at -- at 12:30 p.m.?
12   A    Because --
13   Q    At 12:30 a.m. on the 26th.
14             MR. JEFFERS:   Okay.  0030.
15             MR. JACOBSON:  Yeah.
16             THE WITNESS:   To assess her for
17   her vaginal perineal pain that she was
18   experiencing.
19   BY MR. JACOBSON:
20   Q    Now, the nurses indicate that they
21   asked Dr. Hsieh to see the patient for her
22   restlessness, anxiety, urine output, vitals,
23   that sort of thing, correct?
24   A    In addition, yes.
25             MR. SCHOBERT:   Objection.
0162
 1   BY MR. JACOBSON:
 2   Q    Now, what are Drs. -- Dr. Hsieh's
 3   duties and responsibilities under those
 4   circumstances to this patient?
 5             MR. JEFFERS:   Objection.  Go
 6   ahead.
 7   BY MR. JACOBSON:
 8   Q    What does he have to do?  What's he
 9   expected to do in your exercise of ordinary
10   care?
11   A    Go in -- go in and do what doctors do:
12   history, physical examination.
13   Q    Okay.  Is he expected to review the
14   labs, the most recent labs?
15   A    That could be part of this, yes.
16   Q    Well, Doctor, in the exercise of his
17   duty to this patient, is he required to look
18   at the labs?
19             MR. SCHOBERT:  Objection.
20             THE WITNESS:   Looking at the labs
21   can be part of his assessment, yes.
22   BY MR. JACOBSON:
23   Q    When you say "can be," Doctor, I want
24   to know is -- whether the reasonable
25   physician in the position of Dr. Hsieh would
0163
 1   look at the labs as part and parcel of his
 2   exam at 12:30.
 3             MR. JEFFERS:   Object.
 4             MR. SCHOBERT:  Object.
 5   BY MR. JACOBSON:
 6   Q    Doctor?
 7   A    A reasonable physician would look at
 8   the labs, yes.
 9   Q    Would he look at all the labs, Doctor?
10   A    What do you mean by "all"?
11   Q    Okay.  Would he look at only the H&H?
12   A    Probably.
13   Q    Let me just rephrase it.  Would he
14   discharge his duty to this patient by look
15   -- if he looked only at the H&H and not at
16   the remainder of the labs?
17             MR. SCHOBERT:   Objection.
18             THE WITNESS:   What do you mean
19   "the remainder"?
20   BY MR. JACOBSON:
21   Q    The white blood -- the white count, the
22   immature whites, the HG -- SGOT, SGPT.
23   A    All right.  I think if he looked at the
24   H&H, the platelet count, the overall white
25   count, the liver enzymes and the magnesium
0164
 1   sulfate level, that's what he had a duty to
 2   check.
 3   Q    Okay.  That's the minimum that he's got
 4   to look at to discharge his duty, correct?
 5   A    Correct.
 6   Q    All right. Did -- did you read Dr.
 7   Hsieh's testimony?
 8   A    I did.  I didn't memorize it.
 9   Q    Okay, and do you recall that he had
10   indicated that he felt that he was there
11   simply to evaluate the possibility of a
12   bleed?
13             MR. SCHOBERT:  I'm going to
14   object.
15             MR. JEFFERS:   It's an
16   oversimplification, I think.  Go ahead.
17   BY MR. JACOBSON:
18   Q    Is that your recollection of his
19   testimony?
20   A    In the broadest of terms, perhaps.  Do
21   you have a specific page you want to
22   reference?  We can do that.
23   Q    Well, I don't know how important that
24   is.  I -- I -- I guess my question to you
25   is, Doctor:  would there be a difference in
0165
 1   Dr. Hsieh's duties and responsibilities if
 2   he were asked by Dr. Hahn to look at the
 3   patient for a bleed than if he was asked by
 4   the nurse to look at the patient for a
 5   bleed?
 6             MR. SCHOBERT:  Objection.
 7             MR. JEFFERS:   Go ahead.
 8             THE WITNESS:   No.
 9   BY MR. JACOBSON:
10   Q    Okay.  Would he have a broader duty if
11   he's asked by the nurses rather than Dr.
12   Hahn because the nurse really shouldn't be
13   making a diagnosis?
14   A    No.
15   Q    Okay.  Now, if Dr. Hsieh did not ask or
16   look for the labs when he examined this
17   patient at 12:30, and the nurse was aware
18   that some of the labs were abnormal, did she
19   have a duty to tell Dr. Hsieh that or
20   provide him with the labs?
21             MR. SCHOBERT:   Object.
22             MR. JEFFERS:   Objection.
23             THE WITNESS:   No, sir.
24   BY MR. JACOBSON:
25   Q    Why is that?
0166
 1   A    Dr. Hsieh is making his own,
 2   independent medical assessment and
 3   communicating that with Dr. Hahn.  The
 4   nursing staff does not correct what he is
 5   doing.
 6   Q    Well, if the nurse noticed that he
 7   didn't look at all the labs, does she have a
 8   duty to show him all the labs?
 9   A    No, sir.
10   Q    Okay, even if she knows that there are
11   abnormal labs that he has not seen?
12   A    She has no business doing that.
13   Q    Doctor, what is your personal
14   experience with strep A infections in the
15   puerperal period?  Have you ever treated
16   any?
17   A    No, sir, not of this nature.
18   Q    Well, any strep A infections in the
19   puerperal -- puerperal -- strike that.  What
20   do you mean by "not of this nature"?
21   A    Involving the toxic shock-like syndrome
22   that was seen in this patient.
23   Q    Okay.  So, you've dealt with patients
24   with invasive strep A?
25   A    Yes, sir.
0167
 1   Q    Okay.  How many times?
 2   A    Maybe a half a dozen over 20 years.
 3   Q    In the puerperal period?
 4   A    Yes, sir.
 5   Q    Any of them die?
 6   A    No, sir.
 7   Q    Okay.  Were you able to arrest the
 8   progress, Doctor, of -- of -- of the sepsis
 9   in these patients before they proceeded into
10   shock?
11             MR. JEFFERS:   Objection.
12             THE WITNESS:   Yes.
13             MR. JACOBSON:  Okay.
14             MR. JEFFERS:   What was the
15   answer?
16             THE WITNESS:   The answer is yes.
17   BY MR. JACOBSON:
18   Q    None of them went into shock, correct?
19   A    Some of them got quite sick.
20   Q    But did not go into shock, correct?
21   A    That's correct.
22   Q    All right.  Do you know for a fact,
23   Doctor, that there were toxins in this case?
24   A    They were reported on laboratory tests.
25   Q    Okay.  Can you interpret that for me?
0168
 1             MR. JEFFERS:   What do you mean,
 2   "interpret"?
 3             MR. JACOBSON:  Okay, where?
 4   Where?  Pull it out?
 5             MR. JEFFERS:   What does that
 6   mean?
 7   BY MR. JACOBSON:
 8   Q    Where?  Pull it out.
 9   A    I know I've seen it somewhere.  Testing
10   toxic shock syndrome, CPT, 8609 Test 76679,
11   stat, results detected.
12   Q    Do you know what that means, Doctor?
13   A    No, sir.
14             MR. SCHOBERT:  What page is that
15   on, Doctor?
16             MR. PARIS:   It's page 46.
17   BY MR. JACOBSON:
18   Q    So, you don't know --
19             MR. SCHOBERT:  Forty-six, okay.
20   BY MR. JACOBSON:
21   Q    You do not know from looking at this
22   record, Doctor -- strike that.
23             Doctor, in your patients that had
24   strep A, were they all tested for toxins?
25   A    None of them were.
0169
 1   Q    Okay.  So, they may indeed have had
 2   toxins as well, correct?
 3   A    I don't know.
 4   Q    They might have?
 5   A    They were not tested.  Tests weren't
 6   available when I've seen these patients.
 7   Q    And, Doctor, they might have had
 8   toxins, correct?
 9             MR. JEFFERS:   Objection.
10             MR. SCHOBERT:  Objection.
11   BY MR. JACOBSON:
12   Q    Is that true?
13             MR. JEFFERS:   Objection.
14   BY MR. JACOBSON:
15   Q    You can answer, Doctor.
16   A    I -- I don't know if they had them or
17   not.
18   Q    Okay.  Doctor, do all strep A bacteria
19   release some degree of toxin?
20   A    I don't know that answer.
21   Q    How did you treat your cases of strep,
22   Doctor?
23             MR. JEFFERS:   Objection.
24             THE WITNESS:   Antibiotics.
25   BY MR. JACOBSON:
0170
 1   Q    Any surgical intervention required?
 2   A    Two of them.
 3   Q    Okay.  Did they all have a localized
 4   infection somewhere?
 5             MR. JEFFERS:   Continuing
 6   objection.  Okay.
 7             THE WITNESS:   They had a
 8   clinically obvious infection.
 9   BY MR. JACOBSON:
10   Q    Okay.  Was it -- was it a sepsis,
11   Doctor, or was it a localized infection?
12   A    Would you like to differentiate those
13   two for me?
14   Q    Sepsis, Doctor, is when the bacteria --
15   when you have bacteremia in the bloodstream
16   that deteriorates into shock, correct?
17   A    Not necessarily.  You can have
18   bacteremia that does not progress into
19   shock, and then there can be treatments all
20   along that spectrum.
21   Q    In your patients with strep A, did they
22   all have a localized source of infection?
23   A    They had a source of infection, yes,
24   sir.
25   Q    Okay.  Did they all become septic?
0171
 1   A    What do you mean by "septic"?
 2   Q    What's your understanding of the
 3   definition of that term?
 4   A    Well, like I said, my definition of
 5   infection was that they had consistently
 6   elevated white counts, that they had
 7   consistently elevated fevers, and they had
 8   signs and symptoms of infection as I
 9   previously outlined.
10   Q    Doctor, were all of the localized
11   infections in your patients in the patient's
12   uterus?
13   A    Yes, sir.
14   Q    Doctor, do you have any criticisms of
15   any of the care rendered to this patient by
16   any health care provider?
17             MR. JEFFERS:   Objection.
18             MR. KADLEC:    Objection.
19             MR. SCHOBERT:  Objection.
20             MR. JEFFERS:   Go ahead.
21             THE WITNESS:   Limited -- limiting
22   this opinion to what occurred prior to
23   admission to the Intensive Care Unit of
24   Parma Community, the answer is no.
25   BY MR. JACOBSON:
0172
 1   Q    Do you have any criticisms of the care
 2   that the patient received in the Intensive
 3   Care Unit?
 4             MR. JEFFERS:   Objection.
 5             THE WITNESS:   I don't want to
 6   give myself off an expert in intensive care
 7   unit care.
 8   BY MR. JACOBSON:
 9   Q    Well, Doctor, I --
10   A    I don't have any criticisms of the
11   care, no.
12   Q    Your comments, then, Doctor, on the
13   care in the ICU --
14   A    It was fine.
15   Q    Okay, why do you bring that up, then?
16   A    Well, I didn't, shall we say, in great
17   detail review some of those records, and so
18   if something was brought up --
19   Q    I see.
20   A    -- I didn't want to overstate my
21   position or understate it.
22   Q    Doctor, do you have an opinion as to
23   when this infection began, i.e. the bacteria
24   began to colonize?
25   A    No, sir.
0173
 1   Q    Would the most likely time be rupture
 2   of membranes or delivery or vaginal exam,
 3   Doctor?
 4             MR. JEFFERS:   Objection.  He just
 5   said he had no opinion.
 6             THE WITNESS:   I have no opinion.
 7   BY MR. JACOBSON:
 8   Q    Doctor, would it be fair to say that,
 9   with respect to causation, that -- that you
10   have an opinion that, by the time this
11   infection was recognized, it was too late
12   for this patient to survive?
13   A    I have an opinion that, by the time
14   this infection could be recognized, it was
15   too late.
16   Q    Okay, and when was the time that it
17   could be recognized?
18   A    I told you already that previously.
19   Q    Which was?
20   A    After 8:00.
21   Q    Okay.
22   A    On the morning of the 26th.
23   Q    Okay, but, Doctor, would it be fair to
24   say that you won't be rendering any opinions
25   on whether earlier treatment of the
0174
 1   infection would have resulted in survival?
 2   A    I will not render any opinions; that's
 3   correct.
 4   Q    Okay.  Doctor, if this had been your
 5   patient, at what point would you have come
 6   to the hospital --
 7             MR. JEFFERS:   Objection.  This is
 8   irrelevant.
 9   BY MR. JACOBSON:
10   Q    -- to see her?
11             MR. JEFFERS:   What time "he"?
12   It's an irrelevant question.
13   BY MR. JACOBSON:
14   Q    Doctor, if this had been your patient,
15   at what time?
16   A    In my current circumstance?
17   Q    Yes?
18   A    We're always in the hospital.
19             MR. KADLEC:    Objection.
20   BY MR. JACOBSON:
21   Q    What do you mean by that?
22   A    Our practice is also the house doctors.
23   We have a member of our practice
24   continuously in the hospital 24 hours a day.
25   Q    Whether it was a house doctor, and
0175
 1   there was a house doctor -- I see.  The
 2   house doctor is your partner in this
 3   situation.
 4   A    Yes, sir.
 5   Q    Okay.  Well, let's just say, if you had
 6   been in Dr. Hahn's situation --
 7   A    Right.
 8   Q    -- okay, at what point would you have
 9   come to the hospital to see this patient?
10             MR. SCHOBERT:  Objection.
11             MR. KADLEC:    Objection
12             MR. JEFFERS:   Objection.
13   BY MR. JACOBSON:
14   Q    Not a popular question, but I still
15   need an answer.
16   A    The morning of the 26th.
17   Q    Okay.  Doctor, the antibiotics were
18   ordered for this patient at 10:00 a.m. on
19   the 26th, and they were received at 11:30
20   a.m.  Is that slow?
21   A    I -- I wouldn't characterize it as
22   slow.
23   Q    Slower than normal?
24   A    I -- what do you call "normal"?
25   Q    Well, what would be normal in your
0176
 1   institution, Doctor?
 2   A    It could be an hour.  It could be a
 3   half hour.  It could be ten minutes.  It
 4   could be two hours.  There's a lot of things
 5   that go into it.
 6   Q    Well, if everybody's available, Doctor:
 7   pharmacy, nurses, et cetera, it shouldn't
 8   take more than a half an hour, should it?
 9   A    Commonly, it does not take more than a
10   half hour.
11   Q    All right.  Do you know why it took an
12   hour and a half in this case?
13   A    No, sir.
14   Q    Doctor, at what point would you in your
15   practice transfer a patient to the ICU?
16             MR. JEFFERS:   Object.
17             MR. KADLEC:    Objection.
18             THE WITNESS:   When the patient
19   was unstable.
20   BY MR. JACOBSON:
21   Q    Okay, and when did this patient become
22   unstable, Doctor?
23   A    After 8:00 on the morning of the 26th.
24   Q    Doctor, prior to that time, we have an
25   elevated kidney enzymes, elevated liver
0177
 1   enzymes and lowered blood pressure.  Is that
 2   a patient who's stable?
 3   A    I am sorry.  What are elevated kidney
 4   enzymes?
 5             MR. JEFFERS:   You mean liver?
 6             MR. JACOBSON:  No.
 7             MR. JEFFERS:   Okay.
 8   BY MR. JACOBSON:
 9   Q    BUN, creatinine?
10   A    Those are not enzymes.
11   Q    Pardon me.  Okay.
12   A    What was the question?
13   Q    Let me -- I'll just withdraw that.
14   Give me a minute here.  I'll talk to you for
15   a second.
16             Well, you know, let me just run
17   through this.  Let me just run through some
18   of this legal housekeeping here.
19             MR. PARIS:     Let's go off the
20   camera.
21             (At this time a short recess was
22   had.)
23   BY MR. JACOBSON:
24   Q    Doctor, how many years have you been
25   doing expert consulting?
0178
 1   A    Probably 20.
 2   Q    How many cases do you review per year?
 3   A    Maybe 20 or 30.
 4   Q    Have you ever advertised your services
 5   in a professional journal, Doctor?
 6   A    For being a witness or a consultant?
 7   Q    Yes.
 8   A    In a legal matter?
 9   Q    A consultant, yes.
10   A    No, sir.
11   Q    Did you ever work through a service,
12   Doctor?
13   A    No, sir.
14   Q    About how many times have you consulted
15   with Mr. Jeffers or his firm?
16   A    Twice, I think, with Mr. -- two or
17   three times over ten years with Mr. Jeffers;
18   maybe six times with the firm.
19   Q    Have you ever acted as a consultant for
20   my firm, Nurenberg, Plevin?
21   A    No, I don't think so.
22   Q    Doctor, what percentage of your cases
23   are for plaintiff versus defendant?
24   A    There's somewhere around 75, 80 percent
25   defense, 20 to 25 percent plaintiffs.
0179
 1   Q    Okay.  Now, you say you review about 20
 2   to 30 cases a year?
 3   A    Yes, sir.
 4   Q    Can you give me the names of some
 5   plaintiffs' lawyers locally that have
 6   consulted you in cases in the last two
 7   years?
 8   A    Jane Rua.
 9   Q    Anyone else?
10   A    At the Monteleone firm.
11   Q    Anyone else?
12   A    No.  Well, Peskin, who's now a
13   plaintiff's lawyer, I think.  He used to be
14   with --
15             MR. PARIS:     Defense at Ulmer &
16   Berne.
17             THE WITNESS:   Yes, I've
18   consulted on some cases with him.
19   BY MR. JACOBSON:
20   Q    As -- as an expert on behalf of the
21   plaintiff or defendant?
22   A    Plaintiff.
23   Q    Okay.  Anyone else?
24             MR. JEFFERS:   Could you spell --
25   what was that name?
0180
 1             THE WITNESS:   Peskin.
 2             MR. PARIS:     P-E-S-K-I-N.
 3   BY MR. JACOBSON:
 4   Q    Anyone else?
 5   A    Locally?
 6   Q    Yeah.
 7   A    No, sir.
 8   Q    Have you ever testified on behalf of a
 9   plaintiff in Cuyahoga County or Lake County?
10   A    No, sir.
11             MR. KADLEC:    Object.
12   BY MR. JACOBSON:
13   Q    In court or by deposition?
14   A    No, sir.
15   Q    How many times have you given
16   deposition testimony in the last year?
17   A    Three or four, maybe.
18   Q    Any on behalf of a plaintiff?
19   A    One trial.
20   Q    You testified on behalf of a plaintiff
21   at trial?
22   A    Yes, sir.
23   Q    And who was the plaintiff's lawyer in
24   that case?
25   A    Roseanne Gugino, G-U-G-I-N-O, in
0181
 1   Buffalo, New York.
 2   Q    And did that case involve an infection?
 3   A    No, sir.
 4   Q    Have you ever testified in court in
 5   Cuyahoga County ever on behalf of a
 6   plaintiff?
 7   A    No, sir.
 8   Q    How many times have you testified in
 9   court in Cuyahoga County?
10   A    My best guess would be ten, maybe.
11   Q    Ever testified in Lake County on behalf
12   of a plaintiff, Doctor?
13   A    No, sir.
14   Q    How many times have you testified on
15   behalf of a defendant in Lake County?
16   A    None.
17   Q    Doctor, do you keep a list of -- of
18   your cases that you've testified on?
19   A    No, sir.
20   Q    Have you ever testified in Federal
21   Court?
22   A    I don't think so, but I may not be
23   sophisticated enough to know.  I don't think
24   so.
25   Q    Doctor, I take it that, when you --
0182
 1   strike that.
 2             Doctor, do you have any
 3   correspondence between yourself and Mr.
 4   Jeffers?
 5   A    Not that I've kept.
 6   Q    Okay.  I take it that, when you got the
 7   first communique from Mr. Jeffers, you were
 8   aware that this was probably a case that he
 9   was going to be asking you to defend a
10   hospital's conduct, correct?
11   A    He communicates like he always does,
12   which is:  I have a case.  Would you take a
13   look at the records?  And I said:  yes.
14   Q    All right, and before you even got
15   those records, you knew you were probably
16   going to be asked to defend the conduct of a
17   health care provider, correct?
18   A    No, sir.  I'm asked to render an
19   opinion as to what I think happens in the
20   course of the patient's care, and I do that
21   as honestly as I can.
22   Q    All right.  Well, you were aware, Dr.
23   Duchon, that Mr. Jeffers was hopeful that --
24   strike that.
25             When Mr. Jeffers made the first
0183
 1   communication with you, you were aware that
 2   Mr. Jeffers uniformly defends health care
 3   providers in these types of actions,
 4   correct?
 5             MR. JEFFERS:   But not always.
 6   BY MR. JACOBSON:
 7   Q    Is that correct, Doctor?
 8   A    Mr. Jeffers, to the best of my
 9   knowledge, does a lot of defense work.
10   Q    Has he ever consulted you on a
11   plaintiff's case?
12   A    Not that I'm aware of.
13   Q    How about his firm?
14   A    Not that I'm aware of.
15   Q    Once again, when he -- when he made the
16   first communication with you, was it your
17   expectation that he was sending you a case
18   that he hoped that you would assist in the
19   defense of, Doctor?
20   A    It was -- it's always my expectation I
21   will look at records and render a judgment
22   as to the quality of the care.
23   Q    That's not my question, Doctor.  What I
24   want to know is:  when you got this matter
25   from Mr. Jeffers, okay, was it your
0184
 1   expectation that Mr. Jeffers would be asking
 2   you to defend, if you would be so kind, the
 3   conduct of a health care provider?
 4             MR. JEFFERS:   The reason I
 5   object, and I think what the problem with
 6   the question is, is that it's not how I ask
 7   it.  I ask to have an opinion rendered, and
 8   then I, if those opinions are what I think
 9   they should be, then I use them.  So, you
10   know -- so, I don't think you can ask it
11   that way.
12   BY MR. JACOBSON:
13   Q    Let me rephrase it, okay.  Your
14   understanding of Mr. Jeffers, when you got
15   this case and before, is that he defends
16   health care providers in these types of
17   cases, correct?
18   A    That's my best understanding of his
19   nature of his legal practice.
20   Q    Okay, and it was your expectation and
21   understanding that he would be doing the
22   same thing in this case, correct?
23   A    He sent me records.  I will render an
24   opinion what I think is fair and unbiased.
25   Q    Okay, okay, and it was your
0185
 1   expectation, when he sent you those records,
 2   and understanding, that Mr. Jeffers was
 3   probably defending a health care provider's
 4   conduct, correct?
 5   A    I would have to make that assumption.
 6   Q    All right, and you did make that
 7   assumption, correct?
 8   A    I did make that assumption, yes.
 9   Q    All right.  Now, Doctor, what -- strike
10   that.
11             Doctor, the report that you
12   authored, were there any draft reports?
13   A    No, sir.
14   Q    Doctor, your charges for review of --
15   of a file?
16   A    $300 per hour.
17   Q    Deposition charges?
18   A    $300 per hour.
19   Q    And trial?
20   A    $300 per hour.
21   Q    Doctor, have you ever been consulted in
22   an infectious disease matter or a case
23   involving an infection?
24   A    I'm sure there's been a couple over the
25   years, yes.
0186
 1   Q    Ever in a plaintiff's case?
 2   A    Not that strikes me at the moment, but
 3   there may have been one.  I don't want to
 4   be, you know, disingenuous or anything.  I
 5   -- I don't remember at this point in time,
 6   but it may have happened.
 7   Q    All right.  How about in defense cases,
 8   Doctor?
 9   A    Also, nothing strikes me at this
10   moment.  It may have happened.
11   Q    Doctor, have you done any medical
12   research in preparation for your testimony
13   in this case?
14   A    No, sir.
15   Q    Did you have any notes, Doctor?
16   A    No, sir.
17             MR. JACOBSON:  That's all I've
18   got, Doctor.
19             MR. JEFFERS:   Anybody else?
20             MR. SCHOBERT:  No questions.
21             MR. JEFFERS:   That's it.  Thank
22   you very much.  No waiver.  Can we have more
23   than seven days for him to review it?
24   You'll have the copy, you know.  Yes?  Thank
25   you.
0187
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0188
 1                    CERTIFICATE
 2   The State of Ohio,   )
 3   County of Cuyahoga.  )   SS:
 4       I, Luanne Stone, a Notary Public within
 5   and for the State of Ohio, duly commissioned
 6   and qualified, do hereby certify that the
 7   within-named witness, METHOD A. DUCHON,
 8   M.D., was by me first duly sworn to testify
 9   to the truth, the whole truth and nothing
10   but the truth in the case aforesaid; that
11   the testimony then given by the
12   above-referenced witness was by me reduced
13   to stenotypy in the presence of said
14   witness; afterwards transcribed; and that
15   the foregoing is a true and correct
16   transcription of the testimony so given by
17   the above-referenced witness.
18       I do further certify that this
19   deposition was taken at the time and place
20   in the foregoing caption specified and was
21   completed without adjournment.
22       I do further certify that I am not a
23   relative, counsel or attorney for either
24   party, or otherwise interested in the
25   event of this action.
0189
 1       IN WITNESS WHEREOF, I have hereunto set
 2   my hand and affixed my seal of office at
 3   Cleveland, Ohio this ______ day of
 4   _______________, A.D., 2001.
 5   
 6   
 7                 ____________________________
 8                 Luanne Stone, f.k.a. Protz
 9                 Notary Public
10                 In and for the State of Ohio
11                 My commission expires 4/6/03
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