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 ROBERT FLORA, 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   Friday, the 8th day of June, 2001 at 9:00 
20   o'clock A.M. at the offices of Hanna, 
21   Campbell & Powell, 3737 Embassy Parkway, the 
22   City of Akron, the County of Summit and the 
23   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             Harlan Gordon, 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             Douglas Leak, 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         ROBERT FLORA, M.D., being of lawful 
 3   age, having been first duly sworn according 
 4   to law, deposes and says as follows:
 5     CROSS-EXAMINATION OF ROBERT FLORA, M.D.
 6   BY MR. JACOBSON:
 7   Q    Good morning, Doctor. 
 8   A    Good morning.
 9   Q    Doctor, I'm looking now at a report 
10   which you authored dated December 29, 2000. 
11   Is that your one and only report in this 
12   case, Doctor?
13   A    Yes.
14   Q    Were there any drafts of that report?
15   A    No.
16   Q    Doctor, you indicate in the report that 
17   you did a literature search, and you were 
18   kind enough to present me with that 
19   literature.  Did you rely on that literature 
20   in part for your opinions in this case, 
21   Doctor?
22   A    I -- I did it because it's so rare.  
23   I've only been involved with one case 
24   peripherally in my -- in my medical career, 
25   so I needed some background to at least get 
0004
 1   familiar with the case. 
 2   Q    So, in fact, Doctor, you relied in part 
 3   on your own education and experience, and in 
 4   part on the literature that you reviewed, 
 5   correct? 
 6             MR. SCHOBERT:   Objection.  Go 
 7   ahead. 
 8             THE WITNESS:   Correct. 
 9   BY MR. JACOBSON:
10   Q    All right.  Doctor, can you tell me how 
11   you obtained that literature?  Did you have 
12   a particular search strategy, or did you go 
13   -- exactly what did you do?
14   A    Basically a literature search using the 
15   terms streptococcal, toxic shock and came up 
16   with four articles that I could -- could 
17   obtain.
18   Q    Okay.  Did you make a determination of 
19   whether those articles were reliable, 
20   peer-reviewed articles?
21   A    Well, they're from peer-reviewed 
22   journals.  Whether they're reliable or not, 
23   you know, they're case reports, so I can't 
24   --
25   Q    All right, but they are from -- they 
0005
 1   are from journals which are peer-reviewed 
 2   journals, journals that you think are good 
 3   journals, good reference sources?
 4   A    Not -- not everything that gets 
 5   published in there is necessarily reliable. 
 6   Q    Uh-huh. 
 7   A    So, I -- I -- I -- we teach our 
 8   residents to look at the article, determine 
 9   whether they feel it's reliable and decide 
10   whether they would use it in their clinical 
11   practice.
12   Q    Doctor, you indicate in the 
13   introduction that your review is 
14   specifically focused on Dr. Hsieh's 
15   involvement in this case, correct?
16   A    Correct. 
17   Q    All right.  Doctor, I need to ask you, 
18   however, whether you have any criticisms of 
19   any other health care providers that 
20   rendered care to this patient. 
21             MR. JEFFERS:   Objection. 
22             THE WITNESS:   No, I do not. 
23   BY MR. JACOBSON:
24   Q    Okay.  On the second page, Doctor, at 
25   1730 --
0006
 1   A    Yes.
 2   Q    -- you indicate "Dr. Shagawat in to see 
 3   patient, notation of white blood count 
 4   16,100 but not of differential."  Why did 
 5   you -- why did you note in your chronology, 
 6   Doctor, that Dr. Shagawat failed to note the 
 7   differential?
 8   A    Well, the -- what I mentioned on there 
 9   was I just felt she probably had that 
10   available to her at that time.
11   Q    Uh-huh. 
12   A    And that she just did not make a 
13   notation of what the differential was.
14   Q    Okay.  Doctor, how would you 
15   characterize the differential at that time?
16   A    The differential that was drawn at 
17   1722? 
18   Q    Yes. 
19   A    I'd consider it normal in a postpartum 
20   state.
21   Q    Okay, and, Doctor, what would your -- 
22   what would be your parameters with respect 
23   to bandemia in a postpartum patient?
24   A    In a postpartum patient, I guess I 
25   would need clarification if you're talking 
0007
 1   about just a normal postpartum patient or 
 2   somebody who was complicated with 
 3   preeclampsia.
 4   Q    In this patient, what would your 
 5   parameters be?
 6   A    In this patient somewhere between 15 to 
 7   20.
 8   Q    Okay, and what about left shift, 
 9   Doctor; what would your parameters be for 
10   normal with respect to the other immature 
11   whites? 
12             MR. SCHOBERT:   For this patient 
13   again? 
14   BY MR. JACOBSON:
15   Q    Yes, for this patient again. 
16   A    For this patient? 
17   Q    Yes. 
18   A    I would say left shift -- I guess, what 
19   do you mean by left shift? 
20   Q    In other words, Doctor, what would your 
21   parameters of normal be for the other 
22   immature white blood cells?
23   A    Okay. 
24             MR. SCHOBERT:   For Mrs. Williams?
25             THE WITNESS:   For Mrs. Williams? 
0008
 1             MR. SCHOBERT:   Yes, yes. 
 2             THE WITNESS:   I mean, you can -- 
 3   you can see other parameters, but probably 
 4   more than ten.
 5   BY MR. JACOBSON:
 6   Q    More than ten what?
 7   A    Ten megalomyelocytes or any other 
 8   immature form.
 9   Q    What about neutrophils, Doctor?
10   A    A left shift?  It would be probably 
11   over 80 percent.  
12   Q    Did you think it was important for Dr. 
13   Shagawat to be aware of the differential in 
14   this patient?
15   A    Retrospectively or prospectively? 
16   Q    Prospectively. 
17   A    No. 
18   Q    What about retrospectively?
19   A    Well, I mean, knowing the outcome of -- 
20   of this, you know, if the differential would 
21   have come back abnormal, it may have, but in 
22   this case, it didn't.
23   Q    All right.  Now, at 2024, Dr. Hahn 
24   ordered a urine sample for culture, correct?
25   A    Correct. 
0009
 1   Q    All right.  We can presume, then, that 
 2   Dr. Hahn had a suspicion of infection, 
 3   correct?
 4   A    Of a urine -- a urine infection, 
 5   possibly, yes.
 6   Q    Well, in other words, Dr. Hahn had -- 
 7   had -- obviously had some suspicion of 
 8   infection, or he wouldn't be ordering a 
 9   culture.  It's not a routine thing, correct, 
10   Doctor?
11   A    Well, she had a low grade temp, and one 
12   of the things that it could be was -- is a 
13   urine -- urine infection, yes.
14   Q    Okay.  So, the -- the low grade fever, 
15   Doctor, would give a reasonable physician an 
16   increase in index of suspicion for 
17   infection, amongst other things, correct? 
18             MR. SCHOBERT:   Objection. 
19             MR. LEAK:      Objection. 
20             THE WITNESS:   It could be one of 
21   the things.  There are -- there are other 
22   entities, more -- more probable.
23   BY MR. JACOBSON:
24   Q    Okay.  Well, Doctor, my question to you 
25   is:  a fever of 101.6, does that give the 
0010
 1   reasonable physician a rise in his or her 
 2   index of suspicion for infection, amongst 
 3   other things?  
 4             MR. LEAK:      Objection. 
 5             MR. SCHOBERT:   Objection.  Go 
 6   ahead. 
 7             THE WITNESS:   It can. 
 8   BY MR. JACOBSON:
 9   Q    Is your answer it does, Doctor, or it 
10   should?
11   A    It can.
12   Q    Okay.  Well, should the reasonable 
13   physician have a suspicion of infection with 
14   a patient who has a fever of 101.6? 
15             MR. LEAK:      Objection
16             MR. SCHOBERT:   Objection. 
17   BY MR. JACOBSON:
18   Q    Under these circumstances. 
19   A    Within the first 24 hours? 
20   Q    Uh-huh. 
21   A    No, no. 
22   Q    Doctor, do you have a working 
23   definition of puerperal fever?
24   A    I do.
25   Q    And what is that?
0011
 1   A    It's a -- a fever -- an elevated 
 2   temperature that occurs, you know, 
 3   postpartum, immediately after delivery.  It 
 4   can occur, you know, up to six weeks 
 5   afterwards.
 6   Q    All right.  So, this patient had a 
 7   puerperal fever, correct?
 8   A    She had an elevated temperature, yes. 
 9   Q    Now, Doctor, the patient also had 
10   manifested -- had manifested prior to the -- 
11   prior to the elevated temperature at 7:25 
12   shaking and shivering and complaints of not 
13   feeling well, correct?
14   A    Yes.
15   Q    Okay.  We also had an elevated white 
16   blood count, correct?
17   A    No.  The white blood count was not 
18   elevated.  It was in the normal range.
19   Q    All right.  The patient also reported 
20   as being tired and groggy and having blurry 
21   vision, correct?
22   A    Um, that I'd have to check.  Let's see.
23   Q    Well, assuming -- assuming that's true.
24             MR. SCHOBERT:   All right.  That's 
25   a different question. 
0012
 1   BY MR. JACOBSON:
 2   Q    Assuming that the patient had reported 
 3   at 5:30 being tired and groggy and having 
 4   blurry vision, and we know indeed that this 
 5   patient had had shaking and shivering and a 
 6   complaint of not feeling well, and that at 
 7   7:25 p.m. there is a -- there is a fever, 
 8   would that give the reasonable physician, 
 9   Doctor, a suspicion of infection? 
10             MR. SCHOBERT:   Objection.  
11             MR. LEAK:      Objection. 
12   BY MR. JACOBSON:
13   Q    Amongst other things. 
14   A    Based on this, I would think it would 
15   be more related to the magnesium sulfate. 
16   Q    Doctor, does magnesium sulfate tend to 
17   cause an elevation of temperature?
18   A    No, it does not. 
19   Q    All right, all right.  Once again, 
20   Doctor, would -- would the reasonable 
21   physician, when the temperature goes to 
22   101.6, along with the other things we 
23   described, have a reasonable suspicion for 
24   infection?  
25             MR. LEAK:      Objection. 
0013
 1             MR. SCHOBERT:   Asked and answered 
 2   three times.  Go ahead. 
 3             THE WITNESS:   Can you repeat the 
 4   question, please? 
 5             MR. JACOBSON:  Can you read that 
 6   back? 
 7             (At this time the question was 
 8   read back.)
 9             MR. SCHOBERT:   The same 
10   objection.  Go ahead. 
11             THE WITNESS:   In -- in this 
12   patient, I did -- did not consider that 7:25 
13   is a -- this is within the first 24 hours.  
14   So, I think I mentioned on my -- I consider 
15   an elevated temperature, you know, after the 
16   first 24 hours.
17   BY MR. JACOBSON:
18   Q    Well, Doctor, is there a range of -- of 
19   temperature within the first 24 hours that 
20   would cause you to give rise to concern 
21   about an infection?
22   A    Well, there's -- there's nothing that's 
23   really documented and standardized, but I 
24   would say -- personally, I would say 102, 
25   103.  
0014
 1             MR. JEFFERS:   I couldn't hear 
 2   him. 
 3             THE WITNESS:   One hundred two, 
 4   103.
 5             MR. SCHOBERT:   One hundred two, 
 6   103.
 7   BY MR. JACOBSON:
 8   Q    Doctor, postpartum patients commonly 
 9   will get infections within the first 24 
10   hours, correct?
11   A    They can.
12   Q    It's -- it's not an uncommon 
13   phenomenon, correct?
14   A    It's not very common, no.
15   Q    Well, it's certainly higher -- it 
16   certainly has a higher incidence of 
17   infection than the general population, 
18   correct?
19   A    Comparing somebody who's not pregnant? 
20   Q    Yes. 
21   A    Sure, sure.
22   Q    Now, at 8:20, Dr. Hahn ordered a 
23   culture and sensitivity, so, apparently, he 
24   felt that there was some reasonable 
25   suspicion of infection, correct? 
0015
 1             MR. SCHOBERT:   Objection.  Asked 
 2   and answered.
 3             THE WITNESS:   I can't -- I can't 
 4   answer for him. 
 5   BY MR. JACOBSON:
 6   Q    Okay.  Doctor, if a physician orders a 
 7   culture and sensitivity, wouldn't they have 
 8   a reasonable suspicion of infection, 
 9   correct? 
10             MR. SCHOBERT:   Objection.  Asked 
11   and answered.  Go ahead. 
12             THE WITNESS:   I can't make -- I 
13   can't answer for him, but if there was my -- 
14   if somebody's coming in, and the temperature 
15   is -- is what I consider elevated, then I 
16   would -- I would get a urine culture first, 
17   so -- but I would not get it based on the 
18   101.6.
19   BY MR. JACOBSON:
20   Q    Doctor, when you order a urine culture, 
21   you do it because you have a reasonable 
22   suspicion for infection, correct?
23   A    In -- in a -- in a patient that has a 
24   temperature of 102, 103, yes, I would.
25   Q    I'm -- I'm just talking about 
0016
 1   generically.  When you order a urine 
 2   culture, you're doing it because you think 
 3   there might be an infection, correct?
 4   A    True, the culture.
 5   Q    Now, the culture will not come back for 
 6   quite some time, correct?
 7   A    Forty-eight hours.
 8   Q    All right.  So, when you have this 
 9   hypothetical patient in which you have a 
10   suspicion of infection, and you order a 
11   urine culture, will you also be interested 
12   in -- in what the patient's CBC will show?
13   A    Yes, could be.
14   Q    Okay.  So, in this hypothetical 
15   patient, Doctor, where you have ordered a 
16   urine culture, would you want to know what 
17   the results of the CBC were that were done 
18   three hours later?
19   A    The CBC done at 8:24? 
20   Q    You have a hypothetical patient.  You 
21   suspect your -- your postpartum patient 
22   might have an infection.  You do a urine 
23   culture.   
24   A    Uh-huh.
25   Q    Okay?  Three hours later, a CBC is 
0017
 1   done.  Would you want to know the results of 
 2   that CBC?
 3   A    I personally would want to know it if 
 4   it's abnormal, yes.
 5   Q    Okay.  If you weren't told whether it 
 6   was abnormal, would you ask?
 7   A    No.  It would -- it would -- 
 8   hypothetically, it would depend on what the 
 9   patient's clinical scenario was.
10   Q    Okay. 
11   A    If she was -- she was getting sicker, I 
12   would. 
13   Q    Well, let's assume that the patient 
14   still has an elevated temperature, has a 
15   pulse that's gone to 128, has a -- has a 
16   decreased urine output and anxiety.  Doctor, 
17   with that patient, would you want to know 
18   what the -- what the CBC showed? 
19             MR. SCHOBERT:   Objection.  
20             MR. LEAK:      Objection. 
21             THE WITNESS:   Any -- any -- 
22   please repeat that. 
23   BY MR. JACOBSON:
24   Q    Okay.  You've got a patient who -- a 
25   hypothetical patient, Doctor, that you have 
0018
 1   some suspicion for infection.  You have a 
 2   culture -- pardon me, you order a culture 
 3   and sensitivity of the urine.  Three hours 
 4   later, labs are done.  In the meantime, 
 5   you're informed that the patient has 
 6   anxiety, decreased urine output and a pulse 
 7   rate of 128.  Do you want to know, Doctor, 
 8   or would you want to know what the results 
 9   of the CBC was? 
10             MR. SCHOBERT:   Objection.  Go 
11   ahead.  
12             MR. LEAK:      Objection. 
13             THE WITNESS:   I would in a 
14   patient presenting exactly in that 
15   situation. 
16   BY MR. JACOBSON:
17   Q    All right, and if you were not told by 
18   the nurse, would you ask?
19   A    Yes.
20   Q    All right.  Now, I want you to assume 
21   that Dr. Hahn in this case at 8:20 p.m., 
22   when he ordered the culture and sensitivity 
23   of the urine, I want you to assume that he 
24   had a suspicion that the patient had an 
25   infection, okay?  Assuming that he -- that 
0019
 1   that is true, and assuming that the nurse 
 2   did not tell him the results of the 11:30 
 3   labs in their telephone conversation at 
 4   12:45 a.m., should he have asked?  
 5             MR. LEAK:       Objection
 6             MR. SCHOBERT:   Objection. 
 7             THE WITNESS:   We're talking about 
 8   an assumption in a hypothetical patient? 
 9   BY MR. JACOBSON:
10   Q    We're talking --
11             MR. SCHOBERT:   He's talking 
12   specifically about this case.  
13             MR. JACOBSON:  I want you --
14             MR. SCHOBERT:  He's asking you to 
15   assume -- 
16             MR. JACOBSON:  I want you --
17             MR. SCHOBERT:  -- what Dr. Hahn 
18   thought when he ordered the urine culture.  
19   Otherwise he's talking about this case, I 
20   believe. 
21             MR. JACOBSON:  Yes, that's 
22   correct.
23             MR. JEFFERS:   Are you leaving 
24   out, Bill, for that, because I didn't hear 
25   you go into it, the other information you 
0020
 1   put in it of anxiety, decreased urine and 
 2   pulse of 128? 
 3   BY MR. JACOBSON:
 4   Q    I just want you to assume, Doctor, that 
 5   this is a patient in whom Dr. Hahn, when he 
 6   ordered a culture and sensitivity, had a 
 7   reasonable suspicion of infection. 
 8             THE WITNESS:    I --
 9             MR. SCHOBERT:   Now, let him 
10   finish.
11   BY MR. JACOBSON:
12   Q    When the labs -- assuming that to be 
13   true, when the labs were done three hours 
14   later, if he wasn't told by the nurse about 
15   the -- about the labs, he should have asked, 
16   true? 
17             MR. SCHOBERT:   Objection.  Go 
18   ahead. 
19             THE WITNESS:   He -- he -- he 
20   should ask. 
21   BY MR. JACOBSON:
22   Q    All right. 
23   A    If -- if -- if the patient's situation 
24   was getting worse, he'd want to know the 
25   temperature.
0021
 1   Q    Was this patient's situation getting 
 2   worse, Doctor?
 3   A    Her temperature wasn't going up, no.  
 4   So, it's more of her symptoms were related 
 5   to, I think, other things.
 6   Q    Doctor, what about the urine output; 
 7   would that be cause for some concern?
 8   A    The urine output was normal, in the low 
 9   normal range, and based on my review of 
10   this, the most likely thing was the 
11   excessive blood loss during delivery.
12   Q    What about the pulse rate of 128; is 
13   that of any concern, Doctor?
14   A    In a postpartum patient, no. 
15   Q    What about the anxiety, Doctor?  Is 
16   anxiety normal in a postpartum patient?
17   A    Anxiety is normal in -- in somebody 
18   who's not even postpartum.  The -- the 
19   effect of magnesium can cause anxiety.  As a 
20   house officer, a resident, we used to call 
21   -- get called numerous times because of the 
22   anxiety that patients experienced on it, and 
23   we would have to, you know, evaluate them 
24   for chest pain and other things. 
25   Q    So, in this patient, if Dr. Hahn has a 
0022
 1   suspicion of infection at 8:20 p.m., and her 
 2   course followed the course that we know it 
 3   followed:  she had a repeat temperature of 
 4   100.4; she became anxious, and had urine 
 5   output that was decreased but still within 
 6   the range of normal, a pulse rate of 128, in 
 7   this patient, if Dr. Hahn had a suspicion of 
 8   infection at 8:20 when he ordered the 
 9   culture and sensitivity, if he wasn't told 
10   about the labs by the nurse, should he have 
11   asked? 
12             MR. SCHOBERT:   Objection 
13             MR. LEAK:      Objection. 
14             THE WITNESS:   Yes.
15   BY MR. JACOBSON:
16   Q    All right.  Now, let's move on, Doctor. 
17   In your report, at your -- in -- in your 
18   chronology at 2346, you indicate "lab work 
19   drawn, eventual results of white blood 
20   count, 4.6 but 52 bands."
21   A    Right.
22   Q    Now, Doctor, 52 bands would be well 
23   outside the range of normal in a postpartum 
24   patient, correct?
25   A    Correct.   It would be not normal, yes.
0023
 1   Q    Well, it would be -- it would be well 
 2   out -- you -- you define the range of 
 3   normal, Doctor, as -- as what?
 4   A    Over 20.
 5   Q    Okay.  So, this is well outside the 
 6   range of normal, correct?
 7             MR. SCHOBERT:   Objection. 
 8             THE WITNESS:   It's above normal, 
 9   yes. 
10   BY MR. JACOBSON:
11   Q    Doctor, the presence of 52 bands in 
12   the 11:30 labs should cause the reasonable 
13   physician to be very suspicious for 
14   infection, correct? 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   The normal white 
17   count with 52 bands would -- a reasonable 
18   physician would look at the lab and possibly 
19   assume there's an error. 
20   BY MR. JACOBSON:
21   Q    Okay. 
22   A    Because it doesn't correlate. 
23   Q    All right, and -- and that is because 
24   the white count of 4.6 with 52 bands is so 
25   abnormal that -- that the first thing that 
0024
 1   would occur to you is that this is an error, 
 2   correct?
 3   A    The white count of 4.6 is normal.  The 
 4   52 percent bands is not -- does not go along 
 5   with that, and, so, I would request that it 
 6   be redone.
 7   Q    Immediately?
 8   A    When -- when I have that, yes, reported 
 9   to me, I would ask, because that was an 
10   automated count which tend to be inaccurate. 
11   Q    And, Doctor, you would request that it 
12   be redone immediately because it is such an 
13   unusual result that, if indeed it's an 
14   accurate result, this patient needs to be 
15   treated right away, correct? 
16             MR. SCHOBERT:   Objection. 
17             THE WITNESS:   No. 
18   BY MR. JACOBSON:
19   Q    Well, why would you order the -- the 
20   CBC to be redone right away?
21   A    I would just want to confirm whether 
22   the bands were truly elevated or not. 
23   Q    And if, indeed, they were elevated to 
24   52, Doctor, then what would the standard of 
25   care require?
0025
 1   A    I think I would -- I would have 
 2   further evaluated the patient to see if 
 3   there was an infectious process going on. 
 4   Q    Doctor, can we agree that at 2346 -- or 
 5   strike that.
 6             The labs that were drawn at 11:30, 
 7   Doctor, would mandate to the reasonable 
 8   physician that that physician institute 
 9   antibiotics? 
10             MR. SCHOBERT:   Objection.  
11             MR. LEAK:      Objection. 
12             MR. SCHOBERT:   Asked and 
13   answered.  Go ahead. 
14             THE WITNESS:   No, not with a 
15   white count of 4.6 and un -- unconfirmed 
16   bands, no.
17   BY MR. JACOBSON:
18   Q    Well, if the bands are confirmed? 
19             MR. JEFFERS:   Objection. 
20             THE WITNESS:   Then, what I would 
21   do is evaluate her for an infection. 
22   BY MR. JACOBSON:
23   Q    Yeah, and, Doctor, the evaluation of -- 
24   of -- of infection, I think you're talking 
25   about a clinical evaluation now --
0026
 1   A    Yes.
 2   Q    -- would include what?
 3   A    Chest X-ray, physical exam -- physical 
 4   exam and chest X-ray.
 5   Q    The main thing that you would be 
 6   looking for, Doctor, to see if the -- would 
 7   be to see if the patient was symptomatic in 
 8   any regard, correct?
 9   A    Right. 
10   Q    All right, and you'd look at the vitals 
11   as well, correct?
12   A    Correct. 
13   Q    Now, did this patient have -- have 
14   abnormal vitals? 
15             MR. SCHOBERT:   At any time?  
16             THE WITNESS:   At any time? 
17   BY MR. JACOBSON:
18   Q    No, at -- at -- at 12:30 a.m. right 
19   before you got the lab -- labs.  Temperature 
20   100.4, pulse 128, are those abnormal vitals, 
21   Doctor?
22   A    In this patient who's got preeclampsia 
23   and has undergone a hemorrhage, they -- they 
24   reflect what clinically happened.
25   Q    Blood pressure of 119 over 64, Doctor?
0027
 1   A    It's normal.
 2   Q    Is it normal in a pre-eclamptic patient?
 3   A    Sure, you can have pre-eclamptic 
 4   patients with normal blood pressure.
 5   Q    Doctor, the fact that the urine output 
 6   had dropped from over 100 ccs per hour to 
 7   about 30 ccs per hour, is that something 
 8   that would cause you some concern, Doctor? 
 9             MR. SCHOBERT:   Object.  Asked and 
10   answered for the second or third time.  Go 
11   ahead.
12             THE WITNESS:   It's considered to 
13   be within the normal range, but I think it's 
14   reflective of her postpartum hemorrhage, and 
15   she needed fluid.
16   BY MR. JACOBSON:
17   Q    Doctor, what about the white count 
18   dropping from 17 -- probably 16,100 to 4600; 
19   would that in and of itself be cause for 
20   concern?
21   A    No.
22   Q    In a -- in a six and a half hour 
23   period, it would not be?
24   A    No.
25   Q    Would it be unusual, Doctor, to see 
0028
 1   that?
 2   A    No.
 3   Q    When would you have instituted 
 4   antibiotics in this patient? 
 5             MR. SCHOBERT:   Objection as to 
 6   what he would do, but go ahead and answer 
 7   the question. 
 8             THE WITNESS:   Probably not until 
 9   the morning of the 26th.
10   BY MR. JACOBSON:
11   Q    The morning being what time?
12   A    The 7:45.
13   Q    What about the reduced blood pressures 
14   over the evening, Doctor; would that cause 
15   you any concern?
16   A    Concern about? 
17   Q    Infection. 
18   A    No.
19   Q    Sepsis? 
20   A    No, it -- it -- the concern to me was 
21   that it's -- it's reflecting the 
22   preeclampsia and the hemorrhage and that she 
23   needs -- she needs fluid. 
24   Q    So, you've got a -- let's just assume 
25   hypothetically, Doctor, that you've got a 
0029
 1   CBC with bands of 52, and you repeat it, and 
 2   it's confirmed, and at 1:00 A.M. the patient 
 3   reports uterine pain and cramping.  At 2:30 
 4   a.m., the patient reports their abdomen 
 5   feels hard.  At 3:15 a.m., the nurse 
 6   palpates abdominal distension.  Also, 
 7   Doctor, at 2:15 a.m., we have blood 
 8   pressures of 100 over 44, 88 over 53 and 120 
 9   over 60, and -- and there's a phone call at 
10   3:45.  Does the standard of care require 
11   that antibiotics be given in that situation, 
12   Doctor? 
13             MR. SCHOBERT:   Objection.  Go 
14   ahead.  
15             MR. LEAK:      Objection. 
16             THE WITNESS:   Are we talking 
17   about in this case? 
18   BY MR. JACOBSON:
19   Q    Yes, in this case. 
20   A    In this case, these symptoms go more 
21   like -- are more likely to go with the 
22   preeclampsia and the postpartum hemorrhage.  
23   You know, the abdominal signs can be 
24   reflective of liver damage.
25   Q    Doctor, let's -- let's talk about when 
0030
 1   the reasonable physician prescribes 
 2   antibiotics, okay?  Tell me:  when does the 
 3   reasonable physician -- what's the threshold 
 4   for the prescription of antibiotics? 
 5             MR. SCHOBERT:   This is a generic 
 6   question? 
 7             MR. JACOBSON:   Yeah. 
 8             MR. SCHOBERT:   If you can answer, 
 9   go ahead. 
10             THE WITNESS:   When that physician 
11   -- the physician determines clinically that 
12   there's an overt infection, infectious 
13   process present.
14   BY MR. JACOBSON:
15   Q    All right, and, Doctor, what -- what if 
16   a physician isn't certain but thinks there's 
17   a reasonable possibility or has a reasonable 
18   suspicion of infection; does the physician 
19   have to verify that before they go ahead and 
20   prescribe antibiotics? 
21             MR. SCHOBERT:   Objection.  You 
22   can answer. 
23             THE WITNESS:   There's numerous -- 
24   there's different philosophies on that.  
25   There's people that feel you shouldn't 
0031
 1   because of resistance.
 2   BY MR. JACOBSON:
 3   Q    Did you read the deposition of Dr. 
 4   Duchon, the obstetrician?
 5   A    No.
 6   Q    Do you know Dr. Duchon?
 7   A    No, I do not.
 8   Q    He's -- he's an expert on behalf of the 
 9   hospital, an obstetrician, and he testified 
10   that the reasonable physician prescribes 
11   antibiotics when the reasonable physician 
12   has a reasonable suspicion for infection, 
13   that that is the standard of care.  Do you 
14   disagree with that? 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   I can't comment on 
17   what the standard of care is.  In my -- in 
18   my situation, I would use antibiotics when 
19   I'm convinced that an infectious process is 
20   present. 
21   BY MR. JACOBSON:
22   Q    And what -- what does it take you to 
23   convince -- pardon me, what does it take to 
24   convince you; a positive culture?
25   A    If it's present, yes.
0032
 1   Q    In other words, Doctor --
 2   A    Positive blood cultures --
 3   Q    And --
 4             MR. SCHOBERT:   Wait.  Let him 
 5   finish. 
 6             THE WITNESS:   Positive blood 
 7   cultures, continued high spiking 
 8   temperatures, signs of infection such as, 
 9   you know, foul-smelling lochia.
10   BY MR. JACOBSON:
11   Q    Doctor, in gram positive infections, 
12   you commonly do not get foul-smelling 
13   lochia, correct?
14   A    Not initially. 
15   Q    All right.  What other signs of 
16   infection are you looking for?
17   A    Well, they can have a -- in terms of a 
18   uterine infection, generally they have a 
19   very tender uterus.  It tends to be boggy.  
20   There tends to be discharge, and you see 
21   increased bleeding.
22   Q    Anything else? 
23   A    What are you talking, physical exam? 
24   Q    Yeah. 
25   A    In general, no. 
0033
 1   Q    Doctor, one thing you're looking for is 
 2   -- is a general malaise, a patient who's not 
 3   feeling as well as she should have -- as she 
 4   should, correct?  That's a sign of 
 5   infection, correct?
 6   A    It's a sign of numerous things, 
 7   including somebody who's just delivered and 
 8   had excessive blood loss and is on a 
 9   medication that can give them that feeling.
10   Q    Doctor, a general malaise, in 
11   conjunction with bandemia of 52, would give 
12   rise to a strong suspicion for infection, 
13   correct? 
14             MR. SCHOBERT:   Objection. 
15             THE WITNESS:   If that bandemia is 
16   truly 52 with an elevated white count, it's 
17   a possibility. 
18   BY MR. JACOBSON:
19   Q    I -- Doctor, I want -- with all due 
20   respect, I need an answer -- an answer to my 
21   question, and -- and tell me if I'm right or 
22   wrong, okay?  Am I right that a general 
23   malaise in conjunction with a bandemia of 52 
24   should give a strong suspicion or give rise 
25   to a strong suspicion for infection? 
0034
 1             MR. SCHOBERT:   Objection.  I 
 2   don't like the tone you're taking.  He gave 
 3   you an answer.  If you don't like it, that's 
 4   too damn bad.  I don't like that tone.  If 
 5   you can answer the question, go ahead. 
 6             MR. JACOBSON:  I think my tone is 
 7   fine.  I'm not thrilled with yours. 
 8             MR. SCHOBERT:   Well, you know, 
 9   you get an answer, and then you indicate, 
10   since it's not the one that you want, that 
11   that's not an answer to your question.  Go 
12   ahead, Doctor, if you can answer the 
13   question again.  I'll object. 
14             THE WITNESS:   I do not feel in 
15   this situation, unless she had an elevated 
16   white count, the bands were confirmed, and 
17   there was no other situation going on here, 
18   that -- I would say no.
19   BY MR. JACOBSON:
20   Q    All right.  So, so, I'll move on, 
21   Doctor, but I just want to make sure I 
22   understand.  A general malaise in 
23   conjunction with an elevated white count -- 
24   pardon me.  A general -- a general malaise 
25   in conjunction with bandemia of 52 confirmed 
0035
 1   need not give rise to a suspicion for 
 2   infection, correct?
 3   A    Correct. 
 4             MR. SCHOBERT:  Objection.
 5   BY MR. JACOBSON:
 6   Q    All right.  Now, the -- the phone 
 7   conversation between the nurse and Dr. Hahn 
 8   at 1245 a.m., was it important that the 
 9   bandemia be transmitted to Dr. Hahn?
10   A    If there was an abnormality --
11             MR. JEFFERS:   Objection, by the 
12   way.  The reason I'm objecting is he said he 
13   wasn't commenting upon the care provided by 
14   others but Dr. Hahn.  I think your question 
15   was more -- was wider.  Okay.  I'll just 
16   have a continuing objection. 
17   BY MR. JACOBSON:
18   Q    Okay. 
19   A    Repeat the question, please. 
20   Q    Was it important in the 1245 a.m. 
21   telephone conversation that the bandemia be 
22   transmitted to Dr. Hahn?
23   A    If it was available at 1245, then, it 
24   -- it should -- it should be mentioned to 
25   him. 
0036
 1   Q    Okay. 
 2   A    It's my experience that in these 
 3   situations, they're not available. 
 4   Q    Doctor, in this particular case, did 
 5   you read Nurse Prokop's deposition?
 6   A    I did.
 7   Q    Okay, and was that information 
 8   available at 1245?
 9   A    I -- I can't remember --
10   Q    All right.
11   A    -- what she said.  If you can show me 
12   --
13   Q    Now, different hospitals probably have 
14   different conventions in terms of how a 
15   doctor and nurse talk and what is -- what is 
16   transmitted and how it's transmitted, 
17   correct?
18   A    I can't assume.  I don't know.  I mean, 
19   all I can speak about is what happens in our 
20   hospital.
21   Q    All right, all right, but we can agree, 
22   Doctor, that the standard of care required 
23   that, assuming the information was available 
24   at 1245 a.m., that it be, and I'm talking 
25   about the bandemia now, that that be 
0037
 1   transmitted to Dr. Hahn. 
 2             MR. SCHOBERT:   Objection. 
 3   BY MR. JACOBSON:
 4   Q    Correct?
 5             MR. SCHOBERT:   Objection. 
 6             THE WITNESS:   I can't comment on 
 7   the standard of care.  If it was my patient, 
 8   I would want the bandemia conveyed to me so 
 9   that I can repeat it because -- because I'm 
10   not sure I believe it. 
11   BY MR. JACOBSON:
12   Q    Well, Doctor, you're here as a standard 
13   of care expert, okay? 
14   A    I was brought in to be an expert on the 
15   function of the house officer.
16   Q    Okay, and that house officer is a Board 
17   certified obstetrician, correct?
18   A    I believe so, yes.
19   Q    Okay, as is Dr. Hahn, correct?
20   A    I -- I believe so.  I mean, I can't --
21   Q    Okay.  Are you telling me, Doctor, that 
22   you don't know what the standard of care is 
23   in terms of whether Dr. Hahn need have that 
24   information?  You're not familiar with the 
25   standard of care in that regard?
0038
 1   A    Yes.  I can tell you -- I don't know 
 2   what standard of care is in other hospitals, 
 3   but if it's my patient, I would want to know 
 4   about it, so I would be able to repeat it. 
 5             MR. JEFFERS:   Objection. 
 6   BY MR. JACOBSON:
 7   Q    Okay.  Have you worked at other 
 8   hospitals other than the ones you're working 
 9   at now, Doctor?
10   A    Yes. 
11   Q    In every hospital that you've ever been 
12   associated with, Doctor, would you expect to 
13   be given the information about the bandemia? 
14             MR. JEFFERS:   Object. 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   I would expect, if 
17   it was a patient I was taking care of, I 
18   would want to be notified of it.
19   BY MR. JACOBSON:
20   Q    You would expect to be notified, 
21   correct, Doctor?
22   A    For my patients, yes. 
23   Q    Now, I'm missing something.  
24             MR. GORDON:    What? 
25             MR. JACOBSON:   I'm missing 
0039
 1   something.  Where -- is Dr. Hahn's 
 2   deposition somewhere? 
 3             MR. GORDON:    I have it right 
 4   here. 
 5             MR. JACOBSON:   Did you take my 
 6   copy? 
 7             MR. GORDON:    No.  Here's Dr. 
 8   Hahn's.
 9   BY MR. JACOBSON: 
10   Q    Dr. Hahn testified in his deposition 
11   --
12             MR. JEFFERS:   Page? 
13             MR. JACOBSON:  On page 280. 
14   BY MR. JACOBSON:
15   Q    I'll just -- I'll just read it to you.
16             MR. SCHOBERT:   You have a right 
17   to look if you want, but if you want to let 
18   him read it to you initially, it's up to 
19   you. 
20   BY MR. JACOBSON:
21   Q    He was asked on line nine:
22             "Question: And if you're a 
23   physician at Parma Community General 
24   Hospital, you want to make sure that the 
25   nurses you work with comprehend and 
0040
 1   understand some of the basic things in terms 
 2   of lab findings relative to your patients, 
 3   right?  
 4             "Answer:  I believe that would be 
 5   the responsibility of the hospital to know 
 6   that nurses are capable of interpreting 
 7   laboratory values."  
 8             Do you agree with that? 
 9             MR. SCHOBERT:   Objection. 
10             MR. JEFFERS:   Object.
11             THE WITNESS:   I can't comment.  
12   I'm not familiar with what nurses are 
13   instructed to -- required to know. 
14   BY MR. JACOBSON:
15   Q    Doctor, do you ever give lectures to 
16   nurses?
17   A    Yes.
18   Q    So, you assist in the teaching of 
19   nurses, correct? 
20             MR. SCHOBERT:   Objection. 
21             THE WITNESS:   I have -- I have 
22   taught -- I have given lectures to nurses on 
23   specific subjects.
24   BY MR. JACOBSON:
25   Q    Okay.  Doctor, the nurses that you work 
0041
 1   with, you would expect to under -- them to 
 2   understand what a left shift is, correct? 
 3             MR. SCHOBERT:   Objection. 
 4             THE WITNESS:   No, I don't.  I'm 
 5   not -- I'm not sure that they are taught 
 6   what that is.  They -- they -- they know 
 7   that there's a lab slip that comes up that's 
 8   abnormal.  I'm not sure that they know how 
 9   to interpret it or -- or use it.
10   BY MR. JACOBSON:
11   Q    Would you expect a nurse to understand 
12   that bandemia of 52 potentially represents a 
13   pathological process in the body, Doctor?
14   A    I -- I'm not sure I would expect them 
15   to.
16   Q    Would you expect them to know that that 
17   is well outside the range of normal in a 
18   postpartum patient?
19   A    I wouldn't expect them to, no.
20   Q    Okay.  Doctor, how would you, in one of 
21   your patients -- you've indicated that -- 
22   that you would want to know the bandemia.  
23   How -- how would that -- how would that go 
24   about?  You're called by the nurse.  Would 
25   you ask her what the labs are, or would you 
0042
 1   expect her to tell you the abnormal results?
 2   A    I would ask for labs that I would think 
 3   would be pertinent to this, and in this 
 4   situation, I'd want to know the -- the white 
 5   count --
 6   Q    Okay, and what about --
 7   A    -- which was normal.
 8   Q    And would you also want to know the 
 9   differential?
10   A    Only if the white count was elevated.
11   Q    So, as we sit here today, in this 
12   patient, if Dr. Hahn was never told the -- 
13   the degree of bandemia in the 12:45 phone 
14   call, you have no problem with that? 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   I'm sorry? 
17             MR. JACOBSON:  Correct?
18             MR. SCHOBERT:   Asked and 
19   answered.
20   BY MR. JACOBSON:
21   Q    In the 12:45 phone call --
22   A    Right.
23   Q    -- as we sit here today, if it comes 
24   out at trial that the information about the 
25   52 bands never got to Dr. Hahn, you have no 
0043
 1   problem with that at all, correct?
 2   A    Based on the normal white count, no.
 3   Q    All right.  Now, what about the white 
 4   count; is it absolutely necessary that Dr. 
 5   Hahn be told of the white count?
 6   A    Sure.
 7   Q    All right.  Now, whose responsibility 
 8   is that?  Is that -- is it -- is it the 
 9   nurse's responsibility to tell him the white 
10   count, or is it Dr. Hahn's responsibility to 
11   ask? 
12             MR. SCHOBERT:   Objection.  
13             MR. LEAK:      Objection. 
14             THE WITNESS:   I'm not -- I'm not 
15   sure I could answer that.
16   BY MR. JACOBSON:
17   Q    You would ask, correct?
18   A    If it was my patient, I would ask. 
19             MR. JEFFERS:   Object. 
20   BY MR. JACOBSON:
21   Q    Do you know whether Dr. Hahn testified 
22   as to whether he was informed of the white 
23   count or not?
24   A    I can't recall. 
25   Q    Now, in your chronology, you indicate, 
0044
 1   "Dr. Hsieh to see patient, Re:  Vaginal 
 2   bleeding."  
 3             From what -- where do you derive 
 4   that?
 5   A    From the notes -- the note that Dr. 
 6   Hsieh wrote.
 7   Q    Okay.  Now, is that in conflict with 
 8   the nurse's notes?
 9   A    I don't believe so, no. 
10   Q    The nurse's notes indicate, "Dr. Hsieh 
11   called to room to evaluate patient due to 
12   anxiety, output, vital signs," et cetera.  
13   Is that correct?
14   A    If that's what's written -- is that 
15   what's written in the chart? 
16   Q    Yes. 
17   A    Yes. 
18             MR. SCHOBERT:   You can look at 
19   it.  You don't have to test your memory.  
20   He's just reading from the chart.  
21             THE WITNESS:   Yeah.  What time 
22   was that? 
23             MR. SCHOBERT:   That's 0030. 
24             THE WITNESS:   Okay, yeah, that's 
25   what -- that's what's documented.
0045
 1   BY MR. JACOBSON:
 2   Q    All right.  So, Dr. Hsieh writes that 
 3   he is in to see the patient specifically for 
 4   the purposes of evaluating vaginal bleeding, 
 5   and the nurse's rendition is that he was 
 6   called in -- called in for a broader task, 
 7   correct? 
 8             MR. SCHOBERT:   Objection. 
 9             THE WITNESS:   That's what appears 
10   to be documented.
11   BY MR. JACOBSON:
12   Q    All right.  Now, if, indeed, the nurses 
13   are correct, and he was called in for a 
14   broader task, what are his duties and 
15   responsibilities in that situation?  Number 
16   one, Doctor, did they -- assuming that he's 
17   called in to evaluate the patient's anxiety, 
18   output and vital signs, does he have the 
19   obligation to review the labs? 
20             MR. SCHOBERT:   Objection.  Go 
21   ahead. 
22             THE WITNESS:   No. 
23   BY MR. JACOBSON:
24   Q    Why is that?
25   A    He's not managing the patient.  In this 
0046
 1   situation, he's asked to evaluate specific 
 2   things, you know, the bleeding.  With the 
 3   anxiety, I mean, I'm not sure what he would 
 4   -- they would ask him other than to just 
 5   look at the patient and see how -- and see 
 6   if she's anxious.
 7   Q    When he's asked to evaluate the patient 
 8   due to anxiety, output and vitals, his 
 9   responsibility is to make a reasonable 
10   effort to determine what is causing the 
11   abnormalities of -- of those categories, 
12   correct?
13   A    Correct. 
14   Q    All right.  One possible explanation 
15   could lie in the labs, correct?
16   A    Correct. 
17   Q    All right, but, yet, you don't feel 
18   that -- once again, this is all assuming 
19   that -- that the nurses are correct, and Dr. 
20   Hsieh was called in on this broader task.  
21   Assuming that -- that the nurses are correct 
22   and -- and -- and Dr. Hsieh was called to 
23   evaluate the patient due to anxiety, output 
24   and vital signs, he need not look at the 
25   labs? 
0047
 1             MR. SCHOBERT:   Objection. 
 2   BY MR. JACOBSON:
 3   Q    Correct? 
 4   A    Correct. 
 5   Q    All right. 
 6   A    He can make an assessment based on exam 
 7   -- examination.
 8   Q    Doctor, when you authored your report 
 9   of December 29th, 2000, were you aware that 
10   the nurse's notes had indicated that "Dr. 
11   Hsieh was called to the room to evaluate the 
12   patient due to anxiety, output, vital 
13   signs," et cetera?  Were you aware of that 
14   note?
15   A    Yes. 
16             MR. SCHOBERT:   Objection. 
17   BY MR. JACOBSON:
18   Q    Okay, and why did you choose to omit it 
19   from your chronology?
20   A    I did not intentionally choose to omit 
21   it.  I just --
22   Q    Well, there appears to be a conflict 
23   between what Dr. Hsieh believes he was 
24   called in to evaluate and what the nurses 
25   are indicating he was called in to evaluate, 
0048
 1   correct? 
 2             MR. SCHOBERT:   Objection. 
 3             THE WITNESS:   Okay.  There's a 
 4   difference in what's documented, so I can't 
 5   -- I wasn't there. 
 6   BY MR. JACOBSON:
 7   Q    Did you -- did you -- did you give Dr. 
 8   Hsieh the benefit of the doubt and -- and 
 9   assume that he's telling or that his version 
10   is correct? 
11             MR. SCHOBERT:   Objection. 
12             THE WITNESS:   No.  I looked at 
13   the situation, and just felt that what was 
14   done was appropriate. 
15   BY MR. JACOBSON:
16   Q    But in terms of your chronology, 
17   Doctor, why was the nurse's note omitted?  
18   Why did you indicate, or why did you recap 
19   what Dr. Hsieh had indicated as opposed to 
20   what the nurses had indicated? 
21             MR. SCHOBERT:   Objection.  Asked 
22   and answered.  Go ahead. 
23             THE WITNESS:   I did not 
24   intentionally exclude it, but there was more 
25   information in Dr. Hsieh's note, and this 
0049
 1   is, you know, a generic vital signs, et 
 2   cetera.  I mean, it was just a very generic 
 3   note. 
 4   BY MR. JACOBSON:
 5   Q    Doctor, you indicate in -- in the last 
 6   paragraph of your report, "His evaluations 
 7   were specifically to evaluate for seizure 
 8   activity and postpartum bleeding." 
 9   A    Correct.
10   Q    But that's not correct; is it? 
11             MR. SCHOBERT:   Objection.
12   BY MR. JACOBSON: 
13   Q    It was a broader responsibility than 
14   that. 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   You're making -- he 
17   was asked to assess the postpartum bleeding 
18   which could have been the reason for the 
19   anxiety.
20   BY MR. JACOBSON:
21   Q    If the nurse's -- if -- if the nurse's 
22   note is correct, "Dr. Hsieh called to room 
23   to evaluate patient due to anxiety, output, 
24   vital signs," then your report which 
25   indicates that his evaluations were for 
0050
 1   specifically to evaluate for seizure 
 2   activity and postpartum bleeding, that is 
 3   incorrect. 
 4             MR. SCHOBERT:   Objection. 
 5   BY MR. JACOBSON:
 6   Q    Correct?
 7   A    You make me assume that this is a 
 8   correct note? 
 9   Q    Yes. 
10   A    No.  I mean, I think he was asked to 
11   evaluate the postpartum bleeding, the cause.
12   Q    Let me rephrase the question more 
13   artfully, Doctor, okay?  If the nurse's note 
14   is correct, then, then, your conclusion in 
15   your report is incomplete; would that be a 
16   more fair characterization, Doctor? 
17             MR. SCHOBERT:   Objection.  Asked 
18   and answered. 
19             THE WITNESS:   No, no.
20   BY MR. JACOBSON:
21   Q    It's not?
22   A    I felt that he was asked -- a house 
23   officer is asked to do specific tasks, and 
24   in this situation, you know, he was asked to 
25   evaluate postpartum bleeding which could be 
0051
 1   the reason for the anxiety and output.
 2   Q    But there could be other reasons as 
 3   well, correct?
 4   A    There can always be other reasons.  One 
 5   thing, the situation -- I mean, this was -- 
 6   the patient had a significant postpartum 
 7   hemorrhage.  
 8   Q    Infection can cause anxiety, reduced 
 9   urine output, elevated pulse, correct?
10   A    It can be one of the things that can 
11   cause it. 
12   Q    If, indeed, Dr. Hsieh was called to 
13   evaluate the patient due to anxiety, output, 
14   vital signs, did the standard of care 
15   require him to have infection as part of his 
16   differential?
17   A    He was not asked to -- to evaluate 
18   that.  He was asked to assess the postpartum 
19   hemorrhage, which is what usually house 
20   officers do.  He was not asked to manage the 
21   patient.
22   Q    All right.  Now, I -- I -- I think what 
23   you're trying to tell me here, Doctor, is 
24   that you don't feel he need make a 
25   differential in his mind. 
0052
 1             MR. JEFFERS:   Sorry.  
 2             MR. JACOBSON:  Is that correct? 
 3             MR. JEFFERS:   You put your hand 
 4   up over your mouth.  I couldn't hear you. 
 5   BY MR. JACOBSON:
 6   Q    Pardon me.  You don't think it would be 
 7   necessary for Dr. Hsieh to have a 
 8   differential, correct?
 9   A    Correct. 
10   Q    All right, but when he's evaluating a 
11   patient for anxiety, output and vital signs, 
12   Doctor, isn't it appropriate for Dr. Hsieh 
13   to at least have a -- a spectrum of 
14   possibilities that could be causing these 
15   things? 
16             MR. SCHOBERT:   Objection. 
17   BY MR. JACOBSON:
18   Q    He needs to consider a spectrum of 
19   possibilities that provide an explanation, 
20   correct?
21   A    If he was asked to evaluate the patient 
22   and manage it, then -- then he would, but he 
23   was asked to do a specific task.
24   Q    All right.  No.  If he was -- Doctor, 
25   if he was asked to evaluate the patient for 
0053
 1   anxiety, output and vital signs, is it 
 2   important -- is it appropriate for him to 
 3   consider some possibilities which provide an 
 4   explanation for those things? 
 5             MR. SCHOBERT:   Objection.  Asked 
 6   and answered.
 7   BY MR. JACOBSON:
 8   Q    Is that -- is that what a reasonable 
 9   physician would do? 
10             MR. SCHOBERT:   Objection.  Asked 
11   and answered fifth time. 
12             THE WITNESS:   I think in this 
13   situation, he was asked to evaluate the 
14   bleeding.  He was not asked to --
15   BY MR. JACOBSON:
16   Q    Well, Doctor --
17   A    -- to manage the patient.
18   Q    I want you to assume -- I want you to 
19   -- I'm certainly entitled to ask you to 
20   assume things.  I want you to assume that he 
21   was asked by the nurse to evaluate the 
22   patient for anxiety, output, vital signs.  
23   Assuming that to be true, in that 
24   circumstance, should he have considered 
25   various possibilities as to what might be 
0054
 1   causing those abnormalities? 
 2             MR. SCHOBERT:   Objection, asked 
 3   and answered. 
 4             THE WITNESS:   He should have -- 
 5   he should have assessed what he thought was 
 6   most likely, which in this situation was a 
 7   postpartum hemorrhage.  He did assess it. 
 8   BY MR. JACOBSON:
 9   Q    And if he rules that out, Doctor, is he 
10   required to assess other possibilities that 
11   are secondarily likely?
12   A    For a house officer, no.  They're -- 
13   they're very task oriented, and they're 
14   asked to do specific things.
15   Q    But if their task, Doctor, is to -- is 
16   to determine or evaluate patients due to 
17   anxiety, output and vital signs, he has to 
18   make a reasonable effort to determine what's 
19   causing those things, correct? 
20             MR. SCHOBERT:   Objection, asked 
21   and answered for the tenth time. 
22   BY MR. JACOBSON:
23   Q    Doctor? 
24             MR. SCHOBERT:   Go ahead one last 
25   time.  He's asked you the same question at 
0055
 1   least ten times.  Go ahead. 
 2             MR. JACOBSON:  Can we read back 
 3   the question? 
 4             MR. SCHOBERT:   It doesn't matter. 
 5   You've asked it in 18 different forms.  
 6   You're arguing with him.  He's given you the 
 7   answer.  Go ahead.  Answer it, Doctor, if 
 8   you can. 
 9             MR. JACOBSON:  Can we read it 
10   back? 
11             (At this time the question was 
12   read back.)
13   BY MR. JACOBSON:
14   Q    Isn't that true, Doctor? 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   He was asked to 
17   evaluate the bleeding, and he did 
18   specifically that, which can lead to the 
19   anxiety and output. 
20   BY MR. JACOBSON:
21   Q    But assuming, Doctor, he was asked to 
22   evaluate anxiety, output and vital signs, 
23   assuming that that was what he -- the task 
24   he was given to do, is he then required to 
25   make a reasonable effort to determine what's 
0056
 1   causing those things? 
 2             MR. SCHOBERT:   Objection.  Asked 
 3   and answered ten times. 
 4   BY MR. JACOBSON:
 5   Q    Doctor? 
 6             MR. SCHOBERT:   Doctor, if you 
 7   have a different answer, fine.  If not --
 8             THE WITNESS:   I don't have a 
 9   different answer, no. 
10             MR. JEFFERS:   It smells like 
11   good coffee.
12             MR. GORDON:    What? 
13             MR. JEFFERS:   It smells like good 
14   coffee. 
15             MR. GORDON:    Do you want some? 
16             MR. JEFFERS:   Please.  
17             (At this time a discussion was 
18   held off the record.)
19   BY MR. JACOBSON:
20   Q    Now, you indicate in your report on 
21   page three, the first full paragraph, last 
22   -- last sentence, "Dr. Hahn, not Dr. Hsieh 
23   --" well, let's make it the last two 
24   sentences.  "Dr. Hahn was managing the 
25   problems with disorientation, anxiety, and 
0057
 1   fluid output over the phone.  Dr. Hahn, not 
 2   Dr. Hsieh, was being notified of the 
 3   patient's labs and vitals."  Is that a 
 4   statement you made in your report?
 5   A    Yes. 
 6   Q    Now, assuming that the nurse's note is 
 7   accurate, that Dr. Hahn was called to the 
 8   room to evaluate the patient due to anxiety, 
 9   output, vital signs, then that last sentence 
10   is incorrect; isn't it?  The state -- the 
11   sentence which says, "Dr. Hahn, not Dr. 
12   Hsieh was being notified of the patient's 
13   labs and vitals." 
14             MR. SCHOBERT:   Objection. 
15             THE WITNESS:   He was being -- 
16   well, he was being notified by the nurses of 
17   her labs and vitals.  It's not incorrect.
18   BY MR. JACOBSON:
19   Q    Wait a minute.  Was -- was Dr. Hsieh 
20   notified of the patient's labs and vitals?
21   A    He was notified -- he asked for an H&H 
22   to -- to assess the postpartum hemorrhage 
23   and that's -- and that's, as far as I can 
24   tell, he was notified.
25   Q    Assuming this nurse's note is accurate, 
0058
 1   was Dr. Hsieh notified of the patient's labs 
 2   and vitals?
 3   A    According to Dr. --
 4             MR. SCHOBERT:   Objection.  Go 
 5   ahead. 
 6             THE WITNESS:   -- Dr. Hsieh's 
 7   note, he was notified of the H&H because he 
 8   asked for it.
 9             MR. JACOBSON:   Jeff, you're 
10   going to have to give me a little room here 
11   because I'm not getting a responsive answer. 
12   BY MR. JACOBSON:
13   Q    Doctor, Doctor, assuming that the 
14   nurse's note is accurate, assuming that this 
15   nurse's note is accurate, "Dr. Hsieh called 
16   to room to evaluate patient due to anxiety, 
17   output, vital signs," et cetera, if that's 
18   true, then, Dr. Hsieh indeed -- indeed was 
19   notified of the patient's labs and vitals, 
20   correct? 
21             MR. SCHOBERT:   Objection. 
22   BY MR. JACOBSON:
23   Q    Doctor, your answer? 
24   A    He was notified of the H&H because he 
25   specifically asked for it. 
0059
 1   Q    Was he notified of the patient's labs 
 2   and vitals?  Yes or no? 
 3             MR. SCHOBERT:   Objection.  If you 
 4   know. 
 5             THE WITNESS:   I don't know.
 6   BY MR. JACOBSON:
 7   Q    If the nurse's note was accurate, then 
 8   he was notified of the labs and vitals.
 9             MR. SCHOBERT:   Objection.  That's 
10   not what the note says. 
11             MR. JACOBSON:  Correct?
12             THE WITNESS:   I do not know if 
13   he was notified of the patient's labs and 
14   vitals.  It's documented that Dr. Hahn was. 
15   BY MR. JACOBSON:
16   Q    Doctor, your entire opinion in this 
17   case, your report and your opinion is based 
18   on the assumption that Dr. Hahn was -- was 
19   giving -- given a very specific task to do, 
20   i.e. evaluate for seizure activity and 
21   postpartum bleeding, correct? 
22             MR. SCHOBERT:   You mean Dr. 
23   Hsieh.
24             MR. JEFFERS:   I think you said 
25   Dr. Hahn said that, instead of Dr. Hsieh.
0060
 1             MR. SCHOBERT:  Say it again.
 2   BY MR. JACOBSON:
 3   Q    Let me just start from the beginning.  
 4   Your opinion in this case, your report and 
 5   your opinion is based upon your assumption 
 6   that Dr. Hsieh was given a specific task to 
 7   do, i.e. evaluate for seizure activity and 
 8   postpartum bleeding, correct?
 9   A    Yes.  He was asked, and it's in one of 
10   the depositions; he was asked to evaluate 
11   the seizure activity and, then, he was asked 
12   to evaluate the postpartum bleeding.
13   Q    Now, Doctor, if the premise of your 
14   opinion is incorrect, if, indeed, Dr. Hsieh 
15   was called for a broader task, 
16   hypothetically, would that change your 
17   opinion of what Dr. Hsieh's responsibility 
18   was? 
19             MR. SCHOBERT:   Objection. 
20             MR. JEFFERS:   I don't follow that 
21   question.  There's too much of a jumble. 
22             MR. SCHOBERT:   If you 
23   understand, you can answer again for the 
24   18th time. 
25             MR. JEFFERS:   There's a statement 
0061
 1   and a question, and it's confusing as far as 
 2   I'm concerned.
 3   BY MR. JACOBSON:
 4   Q    All right.  I'll rephrase it.  If Dr. 
 5   Hsieh's note does not adequately express 
 6   what he was called for, if indeed he was 
 7   called for a broader task, would that change 
 8   your opinions in this case? 
 9             MR. SCHOBERT:   Objection. 
10             MR. JEFFERS:   Objection. 
11             THE WITNESS:   No. 
12   BY MR. JACOBSON:
13   Q    And why is that?
14   A    The assessment was being done by the 
15   nurses, and -- and he was specifically asked 
16   to do something that a nurse can't do, which 
17   is do a pelvic exam.  He's there as an 
18   adjunct to do something over and above what 
19   the nurses can do.  The nurses were the ones 
20   that were doing the assessment, and, so, he 
21   did what he was required to do, that he was 
22   capable -- the only one there capable of 
23   doing which is a pelvic exam. 
24   Q    All right.  Let me just move on.  Stay 
25   on page three of your report, if you would.  
0062
 1   You indicate -- pardon me. 
 2             (At this time a discussion was 
 3   held off the record.)
 4   BY MR. JACOBSON:
 5   Q    I'd like you to assume that -- that the 
 6   nurse further notified Dr. Hsieh of the 
 7   bands, the 52 bands.  Assuming that's true, 
 8   and assuming Dr. Hsieh was called to 
 9   evaluate anxiety, output and vitals, so he's 
10   got the information about the bands, and 
11   he's called to evaluate anxiety, output and 
12   vitals, would that change your opinion of 
13   Dr. Hsieh's responsibility in this case? 
14             MR. SCHOBERT:   Objection.  Go 
15   ahead. 
16             THE WITNESS:   If he was notified 
17   of the bands, yes. 
18   BY MR. JACOBSON:
19   Q    All right, and why is that?
20   A    If -- if -- just the bands without the 
21   white count? 
22   Q    If he's notified of the bands. 
23   A    Then he -- he probably should just look 
24   and see if there's any signs of infection, 
25   which would be basically the same exam that 
0063
 1   he did, doing a pelvic exam, and --
 2   Q    But we can agree -- 
 3             MR. SCHOBERT:  Wait.  He's not 
 4   done.
 5   BY MR. JACOBSON:
 6   Q    Pardon me. 
 7   A    -- abdominal exam, uterine tenderness. 
 8   Q    But we can agree that, if he is 
 9   notified of the bands, then he does have the 
10   obligation to check for infection, correct?
11   A    Well, the -- he is not managing the 
12   patient.  It's Dr. Hahn that makes that 
13   decision.  I don't think he can order labs.
14   Q    I'm not talking about ordering labs.  I 
15   just -- you told me just now that, if he 
16   knows about the bands, he should do various 
17   things.
18             MR. SCHOBERT:   Specifically, he 
19   said specific things.
20   BY MR. JACOBSON:
21   Q    All right.  Now, I just want to get to 
22   the origin of that statement, and that is, 
23   Doctor, our agreement that, if he's notified 
24   of the bands, then he's got -- then he has 
25   an obligation to consider infection -- 
0064
 1   infection and do a limited examination for 
 2   it; a fair statement? 
 3             MR. SCHOBERT:   Objection.  Go 
 4   ahead. 
 5             THE WITNESS:   A limited exam.  
 6   What I would recommend first is repeating it 
 7   to make sure it's not abnormal -- it's -- 
 8   it's incorrect. 
 9   BY MR. JACOBSON:
10   Q    All right.  Let me just separate then 
11   the two statements.  If he's told of the 
12   bands, then, number one, he does have an 
13   obligation to consider infection; a fair 
14   statement? 
15             MR. SCHOBERT:   Objection. 
16             THE WITNESS:   If it's -- if it's 
17   a true lab value, then he should do a 
18   cursory exam to look for it. 
19   BY MR. JACOBSON:
20   Q    Okay.  Because if he's told of the 
21   bands, he has an obligation to consider 
22   infection? 
23             MR. JEFFERS:   To what? 
24   BY MR. JACOBSON:
25   Q    True?  To consider infection, true? 
0065
 1             MR. SCHOBERT:   Objection.  Asked 
 2   and answered. 
 3   BY MR. JACOBSON:
 4   Q    True? 
 5   A    He needs to evaluate, yes, do a cursory 
 6   exam to see.
 7   Q    All right. 
 8             MR. JEFFERS:   Can we take a 
 9   two-minute break?  May we? 
10             MR. JACOBSON:   Sure. 
11             THE VIDEOGRAPHER:   Off the 
12   record. 
13             (At this time a short recess was 
14   had.)
15             THE VIDEOGRAPHER:   Back on the 
16   record. 
17   BY MR. JACOBSON:
18   Q    Doctor, you are a Board certified 
19   OB/GYN; is that correct?
20   A    Correct. 
21   Q    You are licensed to practice medicine 
22   in the state of Ohio, correct?
23   A    Correct. 
24   Q    You devote -- you devote the majority 
25   of your professional time to the clinical 
0066
 1   practice of medicine, correct?
 2   A    I devote the majority of my time to 
 3   education, correct. 
 4   Q    And you are an instructor at an 
 5   accredited institution; is that correct, in 
 6   northeast Ohio?
 7   A    I have a teaching appointment at 
 8   northeastern Ohio.
 9   Q    Which is an accredited institution, 
10   correct?
11   A    Correct. 
12   Q    All right.  That's enough.  All right, 
13   Doctor, I want to show you what's been 
14   marked as Exhibit 6 at a previous 
15   deposition.  It's the protocols for an OB 
16   house physician at Parma.  It's specifically 
17   referring to number three, if you'd read 
18   number three over. 
19   A    Okay. 
20   Q    All right.  Doctor, going back to where 
21   we were when we left off, and assuming that 
22   that protocol accurately reflects the duties 
23   and responsibilities of a house officer at 
24   Parma at the time that these events 
25   occurred, if, indeed, the nurse informed Dr. 
0067
 1   Hsieh of the bandemia, did Dr. Hsieh have a 
 2   responsibility to insure that Dr. Hahn was 
 3   told of the bandemia? 
 4             MR. SCHOBERT:   Objection as to a 
 5   hypothetical.  Go ahead. 
 6             THE WITNESS:   Yeah, I -- I would 
 7   -- I would assume that somebody would need 
 8   to inform him.
 9   BY MR. JACOBSON:
10   Q    Okay, and because it's your opinion 
11   that the nurse may not have an understanding 
12   of the significance of the bandemia, that 
13   someone would be Dr. Hsieh, correct? 
14             MR. SCHOBERT:   Objection.
15   BY MR. JACOBSON:
16   Q    He would have a responsibility to 
17   insure that Dr. Hahn was told of the 
18   bandemia, correct? 
19             MR. SCHOBERT:   Objection. 
20             THE WITNESS:   No.  I -- I think 
21   the nurse is more than capable of notifying 
22   the attending if there's an abnormality.
23   BY MR. JACOBSON:
24   Q    Well, all right, Doctor, I -- then 
25   maybe I misunderstand you -- misunderstood 
0068
 1   you earlier.  When the labs came back, and 
 2   they were reported at 52 bands, did the 
 3   nurse have an obligation to tell that to Dr. 
 4   Hahn, whether he asked or not? 
 5             MR. JEFFERS:   Object. 
 6             MR. SCHOBERT:  Objection.
 7   BY MR. JACOBSON:
 8   Q    When she -- when she spoke to him?
 9             MR. SCHOBERT:   We've been over 
10   this. 
11             THE WITNESS:   If it was a patient 
12   of mine, I would want the bands reported to 
13   me.
14   BY MR. JACOBSON:
15   Q    You would expect the nurse to tell you, 
16   to report them to you, correct?
17   A    To me, correct. 
18   Q    If Dr. Hsieh had a suspicion of 
19   infection when he came in to see this 
20   patient, assuming those protocols to be 
21   accurate, did he then have a duty to 
22   communicate that to Dr. Hahn? 
23             MR. SCHOBERT:   Objection as to 
24   the hypothetical.  Go ahead. 
25             THE WITNESS:   I think he would 
0069
 1   just need to make sure that his findings 
 2   were conveyed, whether it was through 
 3   himself direct or through the nurse. 
 4   BY MR. JACOBSON:
 5   Q    Okay.  So, he would have -- he would 
 6   have the obligation to tell the nurse to 
 7   tell Dr. Hahn that he thought there might be 
 8   an infection, correct?
 9   A    He would notify the nurse, yes. 
10   Q    All right.  All right.  Let me move, 
11   then, to the second-last paragraph in your 
12   report, Doctor.  Let me take -- let me take 
13   this back and get it out of your way here. 
14   A    Oh, okay. 
15             MR. GORDON:    Do you want 
16   another one? 
17             MR. SCHOBERT:   If you've got one, 
18   thanks, Harley.  Where are you at, Bill?  
19   I'm sorry.
20   BY MR. JACOBSON:  
21   Q    "This case is proven by the blood 
22   culture." 
23             MR. SCHOBERT:   Okay. 
24   BY MR. JACOBSON:
25   Q    Do you have that in front of you, 
0070
 1   Doctor?
 2   A    Yes. 
 3   Q    Now, Doctor, certainly, strep A can 
 4   produce an invasive infection without toxic 
 5   shock syndrome, correct?
 6   A    Correct. 
 7   Q    All right.  I mean, there is -- there 
 8   is -- one can differentiate between invasive 
 9   strep A infections and streptococcal toxic 
10   shock-like syndrome, correct?  There's a 
11   difference. 
12   A    There's a reported difference, yes. 
13   Q    Okay.  Now, how is it that the blood 
14   culture in your mind proves that this is a 
15   case of toxic shock-like syndrome?
16   A    The blood culture doesn't.  It was the 
17   presence of the -- the report which I have 
18   to look at and find for you, confirming the 
19   presence of the toxin.
20   Q    All right.  So, this is -- this is 
21   actually a misstatement here then?
22   A    Right, right. 
23   Q    All right.  Now, Doctor, are you 
24   familiar with the -- the labs and the 
25   testing that they do at The Cleveland 
0071
 1   Clinic?  Do you know what the report showed?
 2   A    I read the report.  I'm not familiar 
 3   with how the testing's done.
 4   Q    All right.  Now, Doctor, invasive strep 
 5   A will also produce toxins, correct?
 6   A    Not necessarily, no. 
 7   Q    Do you know the answer to that 
 8   question, Doctor?
 9   A    I do not.  I'm not -- I'm not familiar.
10   Q    All right, so, if I were to ask you, 
11   Doctor, whether there is a difference 
12   between toxins produced by invasive strep A 
13   and toxins produced by the bacteria 
14   associated with streptococcal toxic 
15   shock-like syndrome, you would not know an 
16   answer to that; would you, Doctor?
17             MR. SCHOBERT:   Objection. 
18             THE WITNESS:   I didn't catch the 
19   question.
20   BY MR. JACOBSON:
21   Q    I don't think I phrased it all that 
22   well.  Doctor, one thing that -- one theme 
23   that -- that runs throughout the literature 
24   that -- that you have presented us with is 
25   that streptococcal toxic shock-like 
0072
 1   syndrome, typically persons who suffer from 
 2   that illness present with a rapid onset of a 
 3   very high fever, correct?
 4   A    No.  They do not.  It's -- they 
 5   typically do not present with a high fever. 
 6   Q    Well, I -- I'm confused --
 7             MR. SCHOBERT:   If you have  --
 8   BY MR. JACOBSON:
 9   Q    I'm confused by your report.
10             MR. SCHOBERT:   Why don't you ask 
11   the question again just to make sure you 
12   guys are talking about the same thing? 
13   BY MR. JACOBSON:
14   Q    All right.  Don't you say in your 
15   report, "Also they present with very high 
16   fevers"?
17   A    That -- I'm talking about -- there 
18   specifically I'm talking about pelvic 
19   infections just related to Group A strep, 
20   not -- not related to the toxin.  They tend 
21   to have 103, 105 fevers.
22   Q    And -- and patients who have the toxin 
23   don't?
24   A    Don't.
25   Q    Okay. 
0073
 1   A    Right.
 2   Q    So, let me try -- let me make sure I 
 3   understand what you're saying here.  You 
 4   say, "The closer the onset is to the 
 5   delivery, the higher the mortality."  You're 
 6   referring there to toxic shock-like 
 7   syndrome, correct?
 8   A    Correct.
 9   Q    "The presentation is atypical compared 
10   to other causes because the signs of the 
11   pelvic infection are diffuse and 
12   nonlocalizing."  And, I think maybe that's 
13   what's confusing me here. 
14   A    Right.  I'm referring to other pelvic 
15   infections due to other bacteria where you 
16   tend to have more localized symptoms of the 
17   uterus.  You can have boggy, nonfirm 
18   uteruses.  There can be a presence of a 
19   foul-smelling lochia.
20   Q    In other words, are you saying, Doctor, 
21   that the presentation in toxic shock-like 
22   syndrome is different than other infectious 
23   processes because, in other infectious 
24   processes, the signs of pelvic infection are 
25   diffuse and nonlocalizing or are they --
0074
 1   A    No, they are diffuse and localized.
 2   Q    Okay, and -- and in toxic shock-like 
 3   syndrome, they are not?
 4   A    Correct. 
 5   Q    All right. 
 6             MR. SCHOBERT:   It's clear.   
 7             THE WITNESS:   I may not have 
 8   worded it right, but that's exactly what I 
 9   mean.
10   BY MR. JACOBSON:
11   Q    All right, and in -- in other 
12   infectious processes, as -- as opposed to 
13   toxic shock-like syndrome, the patient will 
14   present with a very high fever but not in 
15   toxic shock-like syndrome, correct? 
16             MR. SCHOBERT:   Objection.  I -- I 
17   got lost, but if you understand it, go 
18   ahead.
19             THE WITNESS:   I don't understand 
20   it. 
21   BY MR. JACOBSON:
22   Q    I don't -- I think we -- I actually 
23   think we already established it.  By the 
24   way, Doctor, why is the -- why is it that 
25   the closer the onset is to delivery, the 
0075
 1   higher the mortality?  Do you know why that 
 2   is?
 3   A    I'm not an expert on it.  That's based 
 4   on one of the articles. 
 5   Q    All right.  Now, Doctor, I have in 
 6   front of me four articles, and the first is 
 7   "Streptococcal Toxic Shock Associated with 
 8   Septic Abortion," correct?
 9   A    Correct. 
10   Q    The second is "Life-Threatening --"
11             MR. SCHOBERT:   Go ahead.  If you 
12   want to read with him, that might be 
13   simpler, but I put yours back there. I just 
14   want you to know you have them.
15   BY MR. JACOBSON:
16   Q    The second is "Life-Threatening 
17   Puerperal Infection Due to Group A 
18   Streptococci," correct? 
19   A    Correct.
20   Q    The third is "Serious Group A 
21   Streptococcal Infection around Delivery," 
22   Correct?
23   A    Correct.
24   Q    And the fourth is "Septic Shock and 
25   Pregnancy," correct?
0076
 1   A    Correct. 
 2   Q    Now, there's a difference between 
 3   septic shock and toxic shock, correct?
 4   A    There is.
 5   Q    All right.  Doctor, of these four 
 6   articles, which one is the, or is there only 
 7   one which deals specifically with 
 8   streptococcal toxic shock-like syndrome?
 9   A    Yes, the third one. 
10   Q    That would be "Streptococcal Toxic 
11   Shock Associated with Septic Abortion"?
12   A    No, the "Serious Group A Strep 
13   Infection around Delivery." 
14   Q    But, Doctor, certainly, one can have a 
15   serious Group A streptococcal infection 
16   around delivery which is invasive but not -- 
17   does not amount to toxic shock, correct?
18   A    I'm sorry.  Ask the question again. 
19   Q    You can -- one can certainly have 
20   serious Group A streptococcal infection 
21   around delivery without having streptococcal 
22   toxic shock-like syndrome, correct?
23   A    Correct.  They are two different 
24   syndromes.
25   Q    All right.  All right.  Now, Doctor, in 
0077
 1   this article, "Streptococcal Toxic Shock 
 2   Associated with Septic Abortion," on the 
 3   second page, it says "Discussion."
 4   A    All right. 
 5   Q    And that indicates that, "This 
 6   patient's clinical course illustrates many 
 7   features of streptococcal toxic shock 
 8   including rapidly progressive disease with 
 9   multi-organ system failure.  Patients with 
10   streptococcal toxic shock, regardless of the 
11   site of primary infection, typically present 
12   with acute onset of very high fever and pain 
13   in the affected area after a short flu-like 
14   program of headache, myalgias, vomiting 
15   and/or diarrhea."  
16             Now, Doctor, do you have any 
17   reason to disagree with this article?
18   A    This is an old article from 11 years 
19   ago, and there are newer articles that seem 
20   to indicate that they tend to have -- don't 
21   present -- this is a classic way that they 
22   teach it presents present, but, in general, 
23   when you look at it, it's not very high 
24   fevers. 
25   Q    Doctor, this is the article from which 
0078
 1   you derived the mortality statistics of 30 
 2   to 60 percent which is quoted in your 
 3   report, correct?
 4   A    Yes, it's one -- it's taken from this.
 5   Q    All right.  So, this is an article --
 6   A    I have to just double check.   Yes. 
 7   Q    All right.  So, this is an article, 
 8   "Streptococcal Toxic Shock Associated with 
 9   Septic Abortion," this is at least one of 
10   the articles that you relied on for your 
11   report, correct? 
12             MR. SCHOBERT:   Objection. 
13             THE WITNESS:   Yes, I used one of 
14   the four articles.
15   BY MR. JACOBSON: 
16   Q    All right.  Now, this article 
17   indicating that "patients who have 
18   streptococcal toxic shock regardless of the 
19   site of primary infection typically present 
20   with acute onset of very high fever," 
21   Doctor, you don't agree with that, correct?
22   A    I -- I'm not an expert on this, but if 
23   you read some of the other articles, they do 
24   -- they don't agree with each other.  No, 
25   there's a difference between them.   Even I 
0079
 1   pulled the -- the mortality rate here, but 
 2   if you -- if you look at some of the other 
 3   ones, they're actually higher.
 4   Q    Doctor, the definitive diagnosis of 
 5   streptococcal toxic shock-like syndrome is 
 6   best made with serotyping and analysis of 
 7   toxin, correct?
 8   A    I'm -- I'm -- I'm not an expert on 
 9   that.  I'm not sure, the presence of the 
10   endotoxin, exotoxin.
11   Q    Well, Doctor, on the basis of -- of 
12   clinical presentation and laboratory values, 
13   other than serotyping and analysis of the 
14   exotoxin, it would be very difficult to 
15   differentiate toxic shock-like syndrome from 
16   invasive Group A strep, correct?
17   A    They present differently according to 
18   my general review.  The -- the Group A strep 
19   tends to be high fevers, very sick.  The 
20   toxic strep, toxic shock tends to present 
21   very innocuous and very mild.
22   Q    Doctor, invasive Group A strep, is that 
23   something that you've had experience with as 
24   an obstetrician, as opposed to toxic shock?
25   A    I've been peripherally involved with 
0080
 1   one case.
 2   Q    I'm not talking about shock now.  I'm 
 3   just talking about invasive Group A strep 
 4   with no element of toxic shock.  Have you -- 
 5   have you treated patients for invasive Group 
 6   A strep infections?
 7   A    Vaginal -- pelvic infection? 
 8   Q    Yeah. 
 9   A    No.
10   Q    You have not?
11   A    I have not.
12   Q    All right.  Doctor, from your review of 
13   the literature and your education, training 
14   and experience, can invasive strep A 
15   infection lead to shock, septic shock?
16   A    Yes, any infection can lead to it.
17   Q    Okay.  That's not an uncommon 
18   phenomenon, correct?  If you have an 
19   invasive Group A strep infection which is a 
20   virulent infection, that can lead to shock, 
21   correct?
22   A    That's correct.
23   Q    Do you know, Doctor, whether gram 
24   positive or gram negative infections are 
25   more likely to cause shock?
0081
 1   A    I don't know.
 2   Q    Doctor, any patient who goes into 
 3   shock, you would expect them to have 
 4   laboratory findings such as reduced albumin, 
 5   correct?
 6   A    May or may not.
 7   Q    Okay, but that's associated with both 
 8   toxic and septic shock, correct?
 9   A    It can be.
10   Q    All right, and, Doctor, is -- is a 
11   lowered albumin diagnostic of one or the 
12   other?  Can you look at the albumin and say: 
13   this is toxic shock as opposed to septic 
14   shock?
15   A    I'm not familiar with whether you can 
16   or not.
17   Q    All right.  That's not -- that's not 
18   your understanding, then? 
19             MR. SCHOBERT:   Objection.  That's 
20   not what he said. 
21             THE WITNESS:   I do not have any 
22   familiarity with that, whether it can be 
23   used or not.
24   BY MR. JACOBSON:
25   Q    What about elevated muscle enzymes, 
0082
 1   Doctor; can you look at elevated muscle 
 2   enzymes to differentiate between toxic shock 
 3   and septic shock?
 4   A    I'm not familiar with that.
 5   Q    In all the literature that you 
 6   reviewed, was there anybody who said that 
 7   lowered albumin tends to be more diagnostic 
 8   of toxic shock as opposed to septic shock?
 9   A    I've not seen anything. 
10             MR. SCHOBERT:   Objection.
11   BY MR. JACOBSON:
12   Q    Okay.  That's not in the literature 
13   that you've reviewed, correct?
14   A    That is not. 
15   Q    I'm correct?
16   A    Correct. 
17   Q    All right.  In all of the literature 
18   that you've reviewed, has there -- has there 
19   been anything in that literature which 
20   suggests that elevated muscle enzymes can be 
21   used diagnostically to make a 
22   differentiation between toxic and septic 
23   shock?
24   A    I'm not familiar with any literature on 
25   it.
0083
 1   Q    It's not in the literature that you 
 2   reviewed?
 3   A    No.
 4   Q    Correct?
 5   A    Correct. 
 6   Q    Doctor, the fulminancy of the disease, 
 7   is that something that can be utilized, 
 8   based on the literature you've reviewed, to 
 9   determine or make a determination or 
10   differentiation between toxic shock and 
11   septic shock?
12   A    No. 
13   Q    Low blood pressure, Doctor, in all the 
14   literature that you've reviewed, Doctor, 
15   have you used -- have you seen that utilized 
16   as -- as a method to differentiate between 
17   toxic shock and septic shock?
18   A    No.
19   Q    You get them in both, right?
20   A    You would get it in both. 
21   Q    Doctor, have you reviewed other 
22   literature other than the literature that 
23   you've given us here?
24   A    No. 
25   Q    Well, in -- over the course of your 
0084
 1   career, you've -- you've reviewed literature 
 2   on toxic shock, correct?  I mean, this 
 3   wasn't the first time you've heard of it. 
 4   A    Of strep toxic shock? 
 5   Q    Yeah?
 6   A    This is the first time I've heard of 
 7   it. 
 8   Q    In other words --
 9   A    We talked -- we talked about toxic 
10   shock.
11   Q    Yeah. 
12   A    But I've not been involved in a case of 
13   strep toxic shock.
14   Q    But, Doctor, before you were involved 
15   in this case, you were aware of the 
16   phenomenon of streptococcal toxic shock, 
17   correct?
18   A    Just I've heard of it.  I was not 
19   familiar with it, no.
20   Q    But you've read about it in the 
21   literature, correct? 
22             MR. SCHOBERT:   Objection.  Asked 
23   and answered. 
24             THE WITNESS:   No, I just read 
25   about it.  I had to look up these articles 
0085
 1   because I was not familiar with it, just to 
 2   get a background.
 3   BY MR. JACOBSON:
 4   Q    Well, where -- now, Doctor, the 
 5   mortality rate of 30 to 60 percent for 
 6   streptococcal toxic shock, that is in an 
 7   article in September, 1991, correct?
 8   A    That's what they reported, yes.
 9   Q    Now, Doctor, with -- with better 
10   antibiotics, better surveillance 
11   techniques, better support, would you expect 
12   that ten years later, those statistics would 
13   be somewhat depressed? 
14             MR. SCHOBERT:   Objection. 
15             THE WITNESS:   I -- I can't make a 
16   comment on that. I don't deal with this. 
17   BY MR. JACOBSON:
18   Q    All right.  Doctor, the -- the range of 
19   30 to 60 percent mortality, that's -- that's 
20   a wide range.  Do you have any idea of what 
21   the variables are that go into that range?
22   A    No, I do not.
23   Q    Okay.  Doctor, would you expect that -- 
24   that a patient who is young and healthy has 
25   a better chance of survival as a general 
0086
 1   rule than one who's not? 
 2             MR. SCHOBERT:   Objection. 
 3             THE WITNESS:   I mean, healthier 
 4   compared to? 
 5   BY MR. JACOBSON:
 6   Q    Someone's who's not healthy.
 7   A     Well, I guess in -- are we talking 
 8   about this patient who was not healthy?  I 
 9   mean, this patient was not healthy.  She was 
10   already hemorrhage -- she had a postpartum 
11   hemorrhage.  She had preeclampsia, so there 
12   are numerous variables that would have put 
13   her at higher risk -- higher risk. 
14   Q    Doctor, this patient's heart and lungs 
15   were in pretty good shape, correct?
16   A    I'm -- I'm assuming so.  I wouldn't 
17   know.  I don't know.
18   Q    All right.  As a general rule, Doctor, 
19   this was a young, healthy patient, correct? 
20             MR. SCHOBERT:   Objection.  Asked 
21   and answered. 
22             THE WITNESS:   I would -- as far 
23   as I know, she did not have any medical 
24   problems.
25   BY MR. JACOBSON:
0087
 1   Q    Doctor, the hemorrhage and the fact 
 2   that she had been mildly pre-eclamptic, 
 3   would that affect her inability in any 
 4   fashion to overcome this disease process? 
 5             MR. SCHOBERT:   Objection. 
 6             THE WITNESS:   Well, first, I 
 7   think she was a little bit more than mildly 
 8   pre-eclamptic.  She already had elevated 
 9   liver enzymes, but --
10   BY MR. JACOBSON:
11   Q    Doctor  --
12             MR. SCHOBERT:   Wait, he's not 
13   done.
14   BY MR. JACOBSON:
15   Q    Pardon me. 
16   A    I mean, she -- she was already, you 
17   know, exhibiting some symptoms of the 
18   hypovolemia, so it could -- it could have 
19   affected her ability to withstand the 
20   infection.
21   Q    The elevated liver enzymes, Doctor, 
22   could have been due to an infection as well, 
23   correct?
24   A    Elevated liver enzymes can reflect any 
25   kind of preeclampsia, liver damage and 
0088
 1   infection, yes.
 2   Q    As we sit here today, Doctor, the -- 
 3   the elevated liver enzymes from the labs 
 4   that were drawn at 11:30, can you tell me 
 5   whether they were caused by preeclampsia or 
 6   infection?
 7   A    Prior to when?  I'm sorry. 
 8   Q    The -- the elevated liver enzymes 
 9   you're referring to are the ones that were 
10   drawn at 11:30 p.m. on the 25th, correct? 
11             MR. SCHOBERT:   You can look at 
12   it, Doctor. 
13             THE WITNESS:   No.  Yeah, I need 
14   to.  She was admitted with elevated liver 
15   enzymes on the 20 -- the 24th. 
16   BY MR. JACOBSON:
17   Q    Doctor, you're talking that the SGOT 
18   and SGPT of 33 and 34 respectively are 
19   elevated with the outside of normal of 31, 
20   correct?
21   A    That's what it reads, yes.
22   Q    Doctor, is that -- would -- would you 
23   be -- would you call those abnormal liver 
24   enzymes, Doctor?
25   A    In this patient's clinical scenario, 
0089
 1   yes. 
 2   Q    Okay.  Now, Doctor, after delivery is 
 3   effectuated, as a general rule, the 
 4   preeclampsia gets better, correct?
 5   A    Over time. 
 6   Q    And, yet, 12 hours after delivery, 14 
 7   hours after delivery, the SGOT and SGPT were 
 8   substantially higher elevated, correct? 
 9             MR. SCHOBERT:   Objection. 
10             THE WITNESS:   They were higher 
11   according to the lab values, yes.
12   BY MR. JACOBSON:
13   Q    All right.  Now, as we sit here today, 
14   Doctor, do you have an opinion to a 
15   reasonable degree of medical probability as 
16   to whether the 11:30 labs and the liver 
17   enzymes that are reflected there are due to 
18   preeclampsia or are due to infection, or 
19   can't you say?
20   A    I cannot say.
21   Q    All right. 
22   A    It may take weeks to -- to have this 
23   normalized.
24   Q    All right.  I've lost my train of 
25   thought.  Where was I?  Okay. 
0090
 1             All right.  Once again, Doctor, in 
 2   the mortality statistics, was there anything 
 3   in this patient's presentation, her 
 4   condition, her labs, that would interfere 
 5   with her ability to -- to fight an 
 6   infection, interfere with her body's ability 
 7   to activate compensatory mechanisms before 
 8   midnight on the 25th? 
 9             MR. SCHOBERT:   Objection.  Go 
10   ahead. 
11             THE WITNESS:   I believe that her 
12   state with the preeclampsia and the 
13   hemorrhage may -- may have affected it.
14   BY MR. JACOBSON:
15   Q    Okay.  How so?
16   A    You know, I think with anything else, 
17   there is -- there's significant stress on 
18   her body and it can --
19   Q    So, stress on the body makes it 
20   difficult or more difficult to fight 
21   infection, correct?
22   A    It can.
23   Q    Doctor, do patients who are postpartum 
24   C-section have a tougher time fighting 
25   infections than patients who are -- have 
0091
 1   vaginal deliveries?
 2   A    I'm not -- I wouldn't think so. 
 3   Q    Well, isn't the C-section a greater 
 4   stress on the body than a vaginal delivery?
 5   A    Stress in terms of what? 
 6   Q    Stress in terms of type of stress that 
 7   you describe with respect to the -- the 
 8   hemorrhage and the preeclampsia. 
 9   A    No. 
10   Q    Stress. 
11             MR. SCHOBERT:   Wait.  You've got 
12   to let him finish an answer or let him 
13   finish a question, just so there's some 
14   continuity here.   Go ahead. 
15   BY MR. JACOBSON:
16   Q    All right.  Let's get back to the 
17   variables, Doctor.  In general, patients who 
18   are young and healthy have a more favorable 
19   prognosis when they're afflicted with toxic 
20   shock-like syndrome than those who weren't 
21   young and healthy to begin with, true? 
22             MR. SCHOBERT:   Objection. 
23             THE WITNESS:   I'm not sure.  I 
24   would assume that -- that, you know, if 
25   they're -- they're -- if they have an 
0092
 1   inability to mount the response, that they 
 2   -- they would not have as good a chance to 
 3   withstand it, no.
 4   BY MR. JACOBSON:
 5   Q    So, in general, that is true, correct?  
 6             MR. SCHOBERT:   Objection. 
 7             THE WITNESS:   If they -- if they 
 8   were compromised, yes. 
 9   BY MR. JACOBSON:
10   Q    In -- in addition, Doctor, patients who 
11   have affected hearts, lungs would make it 
12   more difficult for them to compensate when 
13   they go into shock, correct?
14   A    Yes, it can.
15   Q    And those patients when afflicted with 
16   toxic shock-like syndrome would have an 
17   elevated -- elevated mortality over those 
18   who do not, correct? 
19             MR. SCHOBERT:   Objection. 
20             THE WITNESS:   I don't think I can 
21   answer that.  I mean, from my cursory 
22   review, there was nothing that said what 
23   factors predispose them to be able to 
24   withstand it. 
25   BY MR. JACOBSON:
0093
 1   Q    Doctor, would you expect that a 
 2   patient's prognosis would increase the 
 3   earlier they got treatment or become more 
 4   favorable the earlier they got treatment? 
 5             MR. SCHOBERT:   Objection. 
 6             THE WITNESS:   Well, I'm not sure 
 7   what -- what you mean by "treatment."
 8   BY MR. JACOBSON:
 9   Q    Antibiotics. 
10   A    Well, in  -- again, from my review, I'm 
11   not even sure that the antibiotics would 
12   have an effect on here, because the reaction 
13   is due to the toxin, not necessarily the 
14   presence of the bacteria. 
15             (At this time a discussion was 
16   held off the record.)
17   BY MR. JACOBSON:
18   Q    All right.  Doctor, the -- the article, 
19   "Streptococcal Toxic Shock Associated with 
20   Septic Abortion," if we turn to the third 
21   page, Doctor, the last paragraph, it 
22   indicates that "Broad spectrum antibiotics 
23   are advisable because beta-lactam 
24   antibiotics alone may be less effective than 
25   antibiotic combinations that suppress 
0094
 1   protein synthesis .20.  For cases in which 
 2   clinical response to antibiotic therapy is 
 3   not rapid, surgical debridement and 
 4   aggressive supportive care are indicated to 
 5   prevent the high mortality of this disease."  
 6   So, Doctor, in the early stages, at least 
 7   according to this article, the appropriate 
 8   treatment is antibiotic therapy, correct? 
 9             MR. SCHOBERT:   Objection. 
10             THE WITNESS:   According to this 
11   article. 
12   BY MR. JACOBSON:
13   Q    Okay, and, Doctor, once again, does 
14   this article suggest that the earlier 
15   treatment is given, the better the prognosis 
16   is, Doctor? 
17             MR. SCHOBERT:   Objection. 
18             THE WITNESS:   I -- I don't think 
19   it says in here in terms of time factors.  
20   It says whether they respond or not. 
21   BY MR. JACOBSON:
22   Q    Doctor, can we turn to the article, 
23   "Life-Threatening Puerperal Infection Due to 
24   Group A Streptococci," the second last page, 
25   if you would.  The first full paragraph, the 
0095
 1   fifth sentence down after the footnote 13, 
 2   it says, "Although hysterectomy has rarely 
 3   been needed in cases of Group A 
 4   streptococcal puerperal sepsis, we believe 
 5   that timely surgical intervention was 
 6   essential -- essential to the survival of 
 7   our patients."  Now, do you agree with the 
 8   statement that hysterectomy has rarely been 
 9   needed in cases of Group A streptococcal 
10   puerperal sepsis? 
11             MR. SCHOBERT:   Objection. 
12             THE WITNESS:   I think it's 
13   rarely been used since it's a very rare 
14   phenomenon.
15   BY MR. JACOBSON:
16   Q    Well, that's not what it says, though.  
17   It says it's rarely been needed, correct?
18             MR. SCHOBERT:   It says puerperal 
19   sepsis; is this it? 
20   BY MR. JACOBSON:
21   Q    Yeah. 
22   A    I mean, it's an opinion that they're 
23   giving.
24   Q    Do you agree with that opinion?
25   A    I can't really comment since I've never 
0096
 1   --
 2   Q    So, you can't disagree with it either?
 3   A    No, I can't.
 4   Q    Correct?
 5   A    Correct. 
 6   Q    Doctor, I'd like you to assume that 
 7   antibiotics had been given to this patient 
 8   on the 25th or around 1:00 A.M. on the 26th. 
 9   Would she then have had a mortality rate 
10   between 30 to 60 percent? 
11             MR. SCHOBERT:   If -- if -- can 
12   you give me a -- you said on the 25th.  
13   That's a -- that's a broad range.  Are you 
14   saying by  one a.m. on the 26th? 
15   BY MR. JACOBSON:
16   Q    Well, let's just say -- just say 
17   between 7:25 p.m. on the 25th and 1:00 A.M. 
18   on the 26th.  Her mortality, Doctor, would 
19   that have been between 30 to 60 percent? 
20             MR. SCHOBERT:   Objection. 
21             THE WITNESS:   I can't -- I mean, 
22   I don't really have an opinion on that.  I 
23   wouldn't know. 
24   BY MR. JACOBSON:
25   Q    Doctor, would her mortality have been 
0097
 1   improved had antibiotics -- her mortality 
 2   rate, I guess that's a poorly phrased 
 3   question because she died.  Would she have 
 4   had a better chance of survival, Doctor, if 
 5   antibiotics had been instituted earlier? 
 6             MR. JEFFERS:   Objection.
 7             MR. SCHOBERT:   Objection.  
 8             MR. LEAK:      Objection. 
 9             THE WITNESS:   Retrospectively, no.
10   BY MR. JACOBSON:
11   Q    And why is that?
12   A    Well, if you -- if you look at the -- 
13   the second article -- the third article --
14             MR. SCHOBERT:   Give it a specific 
15   name.
16             THE WITNESS:   The Japanese 
17   article, "Serious Group A Streptococcal 
18   Infection around Delivery."
19   BY MR. JACOBSON:
20   Q    Uh-huh. 
21   A    The -- in this -- in their results, 
22   they made a determination based on when -- 
23   when they first started showing signs of 
24   deterioration of what the mortality rate 
25   was, and here, if it was within 12 hours 
0098
 1   after delivery, they had an 88 percent 
 2   mortality rate. 
 3   Q    And, Doctor, is that -- how many 
 4   patients is this study based on in the 
 5   puerperal group?
 6   A    Seventeen.
 7   Q    Is it 13 in the puerperal group or 17?
 8   A    No, 17; 17 in the perinatal and 13 in 
 9   the puerperal. 
10   Q    Okay, and you think that this study is 
11   sufficient to -- to render an opinion, 
12   Doctor, or sufficiently broad and wide-based 
13   in terms of data to render an opinion that 
14   this patient probably would not have 
15   survived, had -- had antibiotics been 
16   instituted earlier?
17   A    Well, this is not a study.  This is 
18   just a report, and since this is so 
19   infrequent, you know, you have to go with 
20   what's -- what's out there, and I can't -- I 
21   can't professionally make my clinical acumen 
22   say that, since I've never seen this, but 
23   this is based on what they could gather on 
24   all the literature that's out there.
25   Q    Doctor, are there larger studies out 
0099
 1   there that deal specifically with toxic 
 2   shock-like syndrome?
 3   A    I'm not aware of them.
 4   Q    Did you make an effort to find them?
 5   A    These -- these were the articles that I 
 6   was able to find in the search.
 7   Q    Well, Doctor, you employed only one 
 8   search strategy, correct?
 9   A    Correct. 
10   Q    All right.  Does toxic shock-like 
11   syndrome come under other names?
12   A    I'm not sure. 
13   Q    Have you -- have you seen it referred 
14   to in -- in the literature in this case, the 
15   depositions, Doctor, as streptococcal toxic 
16   shock-like syndrome or toxic shock syndrome 
17   or streptococcal -- streptococcal shock 
18   syndrome, things like that, Doctor?
19   A    Streptococcal toxic shock syndrome.
20   Q    Okay.  Did you do a search strategy 
21   with that?
22   A    No.
23   Q    Okay.  Doctor, you don't know enough 
24   about this disease process to opine that 
25   this patient probably would have survived 
0100
 1   had antibiotics been given earlier; is that 
 2   true? 
 3             MR. SCHOBERT:   I'm going to 
 4   object to the phraseology.  Go ahead.
 5             THE WITNESS:   I was asked -- I 
 6   was asked to make my opinion on Dr. Hsieh's 
 7   function in -- in this case.  I wasn't asked 
 8   to make an opinion on the outcome of the 
 9   case.
10   BY MR. JACOBSON:
11   Q    Okay, and -- and -- and that's fine, 
12   Doctor, but I just want to make sure I 
13   understand that you don't feel that you're 
14   familiar enough with this disease process to 
15   render opinions on -- on mortality had 
16   treatment been instituted earlier, correct?
17   A    Correct. 
18             MR. SCHOBERT:   I'd have told you 
19   this at the beginning of the depo, but you 
20   would have never believed me, so I let you 
21   get through it. 
22             MR. JACOBSON:   I would have asked 
23   what I asked anyway. 
24             MR. SCHOBERT:   I know, and that's 
25   why I didn't say a word.  Based on the 
0101
 1   questions yesterday to Dr. Armitage, I 
 2   figured you're going to explore it anyways.  
 3   I'm not offering him for the opinions on 
 4   proximate cause, but Bill would have asked 
 5   those questions anyway, Harley, so I figured 
 6   we'd just go there.  
 7             MR. GORDON:    It doesn't matter.  
 8   I shouldn't say "it doesn't matter," because 
 9   I got crunched once.
10             MR. SCHOBERT:   I don't 
11   anticipate, based on his own testimony, 
12   offering him for those opinions.
13   BY MR. JACOBSON:
14   Q    Now, Doctor, in the last paragraph of 
15   your report, you indicate, "The course of 
16   this patient would not have been altered 
17   because of the seriousness of the disease."  
18   What do you mean by that statement?
19   A    Well, retrospectively looking at the 
20   case, I think she developed this early on 
21   after delivery, and just based on what I'm 
22   seeing here, I mean, I can't give an 
23   opinion, but based on what is in here, and I 
24   can't tell you whether it's reliable or not, 
25   it seems to indicate that 88 percent 
0102
 1   mortality rate. 
 2   Q    So, what you've opined in your report 
 3   is that -- is that, and I want to make sure 
 4   I understand what you mean by this.  
 5   Irrespective of what was done for this 
 6   patient, whether it was done differently or 
 7   whether it was done earlier, the die was 
 8   cast for this patient, and she would have 
 9   had the same result, correct?
10   A    With all probability, yes. 
11   Q    But you cannot make that statement to 
12   a reasonable degree of medical probability 
13   because you do not have sufficient 
14   familiarity with this disease process. 
15             MR. JEFFERS:   Objection. 
16             THE WITNESS:   I'm not an expert 
17   on this.
18   BY MR. JACOBSON:
19   Q    Correct?
20   A    I'm not an expert on this. 
21   Q    Doctor, what is the nature of your 
22   current practice?
23   A    I -- I practice as a urogynecologist 
24   and pelvic reconstructive surgeon 40 percent 
25   of my time. 
0103
 1   Q    Forty percent of the time?
 2   A    Right.
 3   Q    And the rest of the practice?
 4   A    I'm not -- in that part, I'm actually 
 5   the residency program director, running a 
 6   teaching program for Summa Health Systems, 
 7   and, so, I oversee house officers, 
 8   residents, medical students.  I also am the 
 9   vice chairman at the medical school.
10   Q    And the rest of -- the rest of your 
11   professional time is your clinical practice, 
12   Doctor?
13   A    Forty percent, yes.
14   Q    I think I'm confused.  Sixty percent of 
15   your time is academic?
16   A    Is academic.
17   Q    Forty percent is clinical?
18   A    Correct. 
19   Q    All right, and within your clinical 
20   practice, what's the breakdown, Doctor, of 
21   -- of gynecologic, urogynecologic and 
22   obstetric?
23   A    The great majority is urogynecologic, 
24   although I also oversee the care the 
25   residents provide to obstetrical and 
0104
 1   gynecologic patients.
 2   Q    Now, one thing, Doctor, I'm not -- I 
 3   guess I better ask.  After this baby's 
 4   delivered and -- and Mrs. Williams is on the 
 5   floor, is she still an obstetrical patient? 
 6   Does that fall within the realm of 
 7   obstetrics, or is she now a gynecologic 
 8   patient?
 9   A    She's an obstetrical patient.
10   Q    Okay.
11             MR. JEFFERS:   Pardon me?
12             THE WITNESS:   Obstetrical 
13   patient. 
14             MR. SCHOBERT:   You have to keep 
15   your voice up. 
16             THE WITNESS:   I'm sorry.
17   BY MR. JACOBSON:
18   Q    And, Doctor, what -- what percent of 
19   your professional time totally is devoted to 
20   the care of obstetrical patients?  Would it 
21   be less than ten percent? 
22             MR. SCHOBERT:   Objection. 
23             THE WITNESS:   I -- I can't really 
24   estimate.  I -- I oversee the obstetrical 
25   care provided by the patients.  I'm 
0105
 1   ultimately responsible.
 2   BY MR. JACOBSON:
 3   Q    How -- how many babies do you deliver 
 4   on a yearly basis, Doctor.  
 5   A    Personally? 
 6   Q    Yeah. 
 7   A    Or --
 8   Q    Personally?
 9   A    Or overseeing the residents?  Probably 
10   one or two a year. 
11   Q    Okay, and would that be in just 
12   emergent situations, Doctor?
13   A    No.  I'm consulted at times.
14   Q    Now, when a patient has delivered and 
15   is taken to the floor, are you responsible 
16   for the patient, or does the patient 
17   typically have an attending that's 
18   responsible other than yourself?
19   A    If it's my patient, I'm responsible for 
20   the patient.
21   Q    So, you do have your own private 
22   patients?
23   A    Yeah.
24   Q    Obstetrical --
25             MR. SCHOBERT:   You can look at 
0106
 1   that.  Do you need to look at it? 
 2             THE WITNESS:   Yeah. 
 3             MR. SCHOBERT:   If it's something 
 4   you need to call, we can take a break.  
 5   Okay, all right, let's keep going. 
 6   BY MR. JACOBSON:
 7   Q    You do -- you do have your own private 
 8   obstetrical patients?
 9   A    I'm consulted at time for obstetrical 
10   care and will get involved as a consult.
11   Q    Okay.
12   A    Doing a Cesarean delivery or -- I've 
13   had my own private practice prior to taking 
14   the residents' program.
15   Q    How long has it been that you've been 
16   in the residency program?
17   A    I've been here since '97. 
18   Q    So -- so, in situations where you are 
19   involved in obstetrical patients are 
20   situations where there is a C-section 
21   involved or some urogynecologic problem, 
22   Doctor, primarily?
23   A    Correct. 
24   Q    All right.  A patient such as -- as 
25   Beth Williams, Doctor, would not fall under 
0107
 1   your care in your current practice, correct?
 2   A    Correct. 
 3   Q    All right, and that's been true for the 
 4   last four years, correct?
 5   A    Correct.
 6   Q    And prior to that time, Doctor, the 
 7   nature of your practice was what?
 8   A    From '91 to '94, I was in full private 
 9   OB/GYN practice.
10   Q    And what percentage of that practice 
11   was devoted to gynecology and urogynecology?
12   A    None was to urogynecology.  It was 70 
13   percent obstetrics, 30 percent gynecologic.
14   Q    And from '94 to '97, Doctor?
15   A    It was in advanced training for the 
16   urogynecology.
17   Q    So --
18   A    As well as a faculty member overseeing 
19   obstetrical and gynecologic patients.
20   Q    So, the last time you would have cared 
21   for a patient such as Mrs. Williams would 
22   have been '94; is that correct?
23             MR. SCHOBERT:   Objection. 
24             THE WITNESS:   That I would 
25   personally take care of them as my private 
0108
 1   patient, yes.
 2   BY MR. JACOBSON: 
 3   Q    Yes. 
 4   A    I oversee patients, obstetrical 
 5   patients of the residents.
 6   Q    So -- so, I want to make sure I 
 7   understand.  Indeed, then, you are an 
 8   attending for a patient such as Mrs. 
 9   Williams; is that correct?
10   A    I'm an attending of record for patients 
11   of the residents at our teaching 
12   institution.
13   Q    Well -- well, can you --
14   A    And I oversee them.
15   Q    Well, can the residents admit patients?
16   A    Can residents admit?  No.
17   Q    Okay.  So, you do admit patients such 
18   as Mrs. Williams; is that correct?
19   A    Correct. 
20   Q    Will you assist in the deliveries, 
21   Doctor?
22   A    I'm sorry? 
23   Q    When -- when you have a patient such as 
24   Mrs. Williams who's admitted under your 
25   care, will you assist in the delivery?
0109
 1   A    Yes.
 2   Q    All right. 
 3   A    And presence.
 4   Q    But typically you'll let the resident 
 5   do it, though?
 6   A    Right, with them, do it with them.
 7   Q    All right.  Doctor, your attributions 
 8   to the literature, Doctor, have they been 
 9   primarily in the area of gynecology and 
10   urogynecology?
11   A    Primarily, yes. 
12   Q    All right.  So, certainly you've never 
13   written on the topic of a diagnosis or 
14   treatment of infection, correct?
15   A    No, I have.
16   Q    Okay, and where is that?
17   A    That is -- it's due to be published in 
18   July of this year, and it's -- I'll show 
19   you, on page  -- it's "Pelvic Inflammatory 
20   Disease, Experts' Guide to Infectious 
21   Disease for Primary Care Physicians." 
22   Q    Doctor, can I get a copy of the 
23   manuscript?
24   A    I -- I can give it to you, yes.  I 
25   don't have it with me.
0110
 1   Q    All right.  I would request that and 
 2   like to get it as soon as possible.  And, 
 3   Doctor, what are the topics that you deal 
 4   with in that manuscript?
 5   A    Just the general approach to -- just an 
 6   overview of pelvic inflammatory disease, 
 7   diagnosis, treatment.
 8   Q    Well, is it -- is it -- does it deal 
 9   with pelvic inflammatory disease as a 
10   separate entity to infection?
11   A    Yes.  It's focused on pelvic 
12   inflammatory disease.
13   Q    Okay.  Which is not infection, correct?
14   A    Of course, it's infection, yes.  It's 
15   an infection -- it's a disease due to 
16   infectious process usually related to 
17   gonorrhea, chlamydia.
18   Q    Is it -- is it -- is it primarily 
19   gynecologic, though, Doctor?
20   A    Yes.
21   Q    All right.  You've never written on the 
22   diagnosis and treatment of puerperal 
23   infection, correct?
24   A    Correct. 
25             MR. JACOBSON:  I still would like 
0111
 1   a copy of the transcript.
 2             MR. SCHOBERT:   Sure.
 3   BY MR. JACOBSON:
 4   Q    Of the manuscript, please.  Any other 
 5   articles, Doctor?
 6   A    Several articles on urogynecologic 
 7   topics.
 8   Q    Any -- any other articles --
 9             MR. SCHOBERT:   I think he was -- 
10   yeah, he was talking  -- he didn't finish 
11   his question, but he inferred infection in 
12   his question to you, any other articles on 
13   infection.
14   BY MR. JACOBSON:
15   Q    Diagnosis and treatment of infection. 
16   A    No. 
17   Q    How long have you been reviewing 
18   medical/legal cases, Doctor?
19   A    This is my first. 
20   Q    And how did you happen to get involved 
21   in this one?
22   A    I was contacted by Jeff Schobert.
23   Q    Do you know how he got your name?
24   A    I know him from the past. 
25   Q    In what context?
0112
 1   A    I -- I used him to represent me as -- 
 2   in a PIE case when they went under. 
 3   Q    Okay.  So, that wasn't a malpractice 
 4   case, then, or it was?
 5   A    No, it was a malpractice case. 
 6   Q    Okay.
 7   A    PIE went under, and I got somebody to 
 8   protect my interest.
 9   Q    Okay.  So, Mr. Schobert has acted as 
10   your personal counsel, correct?
11   A    Correct. 
12   Q    Is that case resolved now?
13   A    Yes, I was dropped.
14             MR. SCHOBERT:   Every so often we 
15   get it right. 
16   BY MR. JACOBSON:
17   Q    Doctor, did that case involve the 
18   diagnosis or treatment of an infection?
19   A    Yes, it did, pelvic inflammatory 
20   disease.
21   Q    Who was the plaintiff's lawyer in that 
22   case?  Do you recall?
23   A    I -- I'd have to look it up.  I don't 
24   -- I don't recall.  It was in Toledo. 
25   Q    Where was the case?
0113
 1   A    In Toledo.
 2   Q    In Toledo? 
 3   A    Yeah.
 4   Q    Do you remember the name of the patient?
 5   A    Sheronda Williams.
 6   Q    Sheronda Williams?
 7   A    Williams.
 8   Q    And it was filed in Lucas County in 
 9   Toledo?
10   A    Correct.
11   Q    Did you give a deposition in that case?
12   A    No, I did not. 
13   Q    Okay.  What are your charges, Doctor, 
14   for review of a case?
15   A    Two hundred fifty dollars an hour.
16   Q    And for deposition?
17   A    The same. 
18   Q    Okay, and for trial testimony?
19   A    The same. 
20   Q    Would that include your travel time as 
21   well?
22   A    Yes. 
23   Q    Do you know Dr. Martin Gimovsky?
24   A    I have met him.
25   Q    Okay.  In what context?
0114
 1   A    Academic meetings.  He's made 
 2   presentations.  I've met him socially in -- 
 3   in New York at some functions.
 4   Q    So, you -- you've been in attendance at 
 5   presentations that he has made?
 6   A    Correct. 
 7   Q    He is -- is he someone who is highly 
 8   regarded by his peers? 
 9             MR. SCHOBERT:   Objection. 
10             THE WITNESS:   He's -- he's -- I'm 
11   not sure what the definition of "highly 
12   regarded" is.
13   BY MR. JACOBSON:
14   Q    Do you hold him in high regard?
15   A    No, I don't. 
16   Q    What did you think -- what did you 
17   think of his lectures?
18   A    Interesting.  His education -- or his 
19   lectures related more to education.
20   Q    Have you ever served as a house officer?
21   A    Yes.
22   Q    Okay, when?
23   A    I served as a house officer from 1980 
24   -- '89 through 1991 at Mercy Hospital in 
25   Toledo.  I also set up the hospital -- house 
0115
 1   officer program at Flower Hospital in 
 2   Sylvania in 1991.
 3   Q    What hospitals do you currently have 
 4   privileges at?
 5   A    Akron City Hospital, or Summa Health 
 6   System and Akron General Medical Center.
 7   Q    Do you know Dr. Hsieh or Dr. Hahn?
 8   A    No. 
 9   Q    Have you ever had a social relationship 
10   with Mr. Schobert?
11   A    No.
12   Q    Have you ever have had dinner with him, 
13   lunch, anything like that?
14   A    No. 
15             MR. SCHOBERT:   Nobody likes me.
16   BY MR. JACOBSON:
17   Q    How did you happen to retain Mr. 
18   Schobert to represent you as personal 
19   counsel? 
20   A    Um, my personal lawyer for my finances 
21   was in the same group, Jim Krause -- 
22   Buckingham, I'm sorry.
23   Q    Doctor, are you -- are you familiar 
24   with the AWON standards?  Have you ever 
25   looked those over?
0116
 1   A    I have not looked them over.  I'm aware 
 2   that they're out there.
 3   Q    Doctor, can we agree that obstetrical 
 4   nurses have the duty to exercise their 
 5   independent judgment in the care and 
 6   treatment of their patient?
 7   A    To their ability, yes. 
 8   Q    Okay.  That is something that -- that 
 9   AWON indicates is required of an obstetrical 
10   nurse, correct? 
11             MR. SCHOBERT:   Objection.
12             THE WITNESS:   I'm not sure.  I'm 
13   not familiar with what their requirements 
14   are.
15   BY MR. JACOBSON:
16   Q    But that is something you would expect, 
17   correct? 
18             MR. SCHOBERT:   Objection. 
19             THE WITNESS:   I'm sorry? 
20   BY MR. JACOBSON:
21   Q    That is something you would expect?
22   A    That they would confirm with what their 
23   knowledge is? 
24   Q    They would exercise their independent 
25   judgment to their ability.
0117
 1             MR. SCHOBERT:   Objection. 
 2             THE WITNESS:   To their ability, 
 3   what they're allowed to do, yes. 
 4   BY MR. JACOBSON:
 5   Q    If a nurse, by the exercise of her 
 6   independent judgment, feels that the patient 
 7   is not receiving appropriate care, does the 
 8   nurse have the duty to speak out on behalf 
 9   of her patient? 
10             MR. SCHOBERT:   Objection.  Go 
11   ahead.  
12             MR. LEAK:      Objection. 
13             MR. JEFFERS:   Object.
14             THE WITNESS:   I don't know what 
15   the policy is in the hospital.  Other 
16   hospitals may have different things than how 
17   they -- in how they address that.
18   BY MR. JACOBSON:
19   Q    Is there a chain of command, Doctor, in 
20   the institutions in which you currently 
21   work?
22   A    In our institution, if there's any 
23   question, then, they do go to the charge 
24   nurse.
25   Q    Well, before -- before the nurse goes 
0118
 1   to the charge nurse, the nurse should speak 
 2   to the physician, correct? 
 3             MR. SCHOBERT:   Objection.  Go 
 4   ahead. 
 5             THE WITNESS:   Yes.
 6   BY MR. JACOBSON:
 7   Q    All right.  Doctor, that's true in 
 8   every circumstance, whether there's a 
 9   written chain of command protocol or not, 
10   correct? 
11             MR. SCHOBERT:   Objection. 
12             THE WITNESS:   If it was a 
13   patient of mine, I would expect that, you 
14   know, she'd discuss it with me before going 
15   to somebody else, yes. 
16   BY MR. JACOBSON:
17   Q    If the nurse feels, Doctor, that a 
18   patient is not receiving appropriate care, 
19   Doctor, you would expect that patient to -- 
20   to tell you, correct?  Pardon me, the nurse 
21   should tell you. 
22             MR. SCHOBERT:   The nurse? 
23             MR. JACOBSON:  Yeah. 
24             THE WITNESS:   I didn't --
25             MR. SCHOBERT:   I'll object.
0119
 1   BY MR. JACOBSON: 
 2   Q    Correct?
 3   A    I would expect her to discuss what's -- 
 4   what's going on and what she doesn't agree 
 5   with.
 6   Q    All right.  Now, that's different than 
 7   simply reporting, calling you up and saying:  
 8   the patient has A, B and C.  In other words, 
 9   we can differentiate that from a discussion 
10   where the nurse says:  the patient has A, B 
11   and C, and I'm concerned that things aren't 
12   right, correct? 
13             MR. SCHOBERT:   I'm going to 
14   object. 
15             MR. JEFFERS:   I don't know what 
16   the question is.
17             THE WITNESS:   I don't know what 
18   the question is.
19             MR. JACOBSON:  All right. 
20             (At this time a discussion was 
21   held off the record.)
22             MR. JACOBSON:   Give me a second. 
23             THE VIDEOGRAPHER:   Off the 
24   record. 
25             (At this time a short recess was 
0120
 1   had.)
 2             THE VIDEOGRAPHER:   Back on the 
 3   record. 
 4   BY MR. JACOBSON:
 5   Q    Doctor, did you make any personal notes 
 6   in your review of this case, jot anything 
 7   down?
 8   A    No, just typed the report. 
 9   Q    Doctor, when were you first consulted 
10   in this case? 
11   A    Um, I believe early December.
12   Q    Okay, and had your PIE matter resolved 
13   at that time?
14   A    It resolved almost a year ago.
15   Q    Okay.  So, it was resolved before you 
16   were asked to get involved in this case, 
17   correct?
18   A    Correct. 
19   Q    Doctor, you mentioned that you would 
20   have been suspicious that there was an error 
21   in the labs.  Why with a 52 percent bands?
22   A    Well, the -- if you look at the lab 
23   result -- report, I mean, it was an 
24   automated test, and, you know, in general, 
25   you know, one out of five tests come back 
0121
 1   wrong.  So, when -- you know, when -- when 
 2   you look at that, the first thing you'd want 
 3   to know is: is it correct, and you'd ask to 
 4   repeat it, and then when they did get a 
 5   repeat at 5:30, the bands were back in the 
 6   normal range of 15.  So, based on 
 7   retrospectively looking at it, I think that 
 8   was wrong.
 9   Q    Doctor, when the body's immune systems 
10   are -- are -- are so stressed, or -- strike 
11   that.
12             When the body's immune systems are 
13   extremely stressed, do you -- do you tend to 
14   then get reversal of -- of elevations of 
15   white counts and immature white counts?  
16   Does there come a point in the infectious 
17   process when you'll start to get lowering of 
18   those things?
19   A    Yes, when they're in the severe septic, 
20   you can see the white count drop below 
21   normal.
22   Q    All right.  Well, you can also see, 
23   Doctor, a white count in the normal range, 
24   but the absolute -- in terms of the absolute 
25   value, but a drop from an elevated white 
0122
 1   count to a normal white, correct? 
 2             MR. SCHOBERT:   Objection. 
 3   BY MR. JACOBSON:
 4   Q    Well, Doctor, if a patient had -- had a 
 5   white count of 100,000, and six hours later, 
 6   the white blood count went down to 5,000, 
 7   would that concern you? 
 8             MR. SCHOBERT:   Objection.  Go 
 9   ahead. 
10             THE WITNESS:   Theoretically? 
11   BY MR. JACOBSON:
12   Q    Yes. 
13   A    No.  I actually would be happy it 
14   dropped back in the normal range.
15   Q    Doctor, you would be concerned that 
16   these labs were erroneous because --
17             MR. SCHOBERT:   No, no.  Come on, 
18   let's go.
19   BY MR. JACOBSON:
20   Q    -- the degree of bandemia is so high 
21   that it makes you suspicious for error, 
22   correct?
23   A    It's -- it's elevated, so I would want 
24   to know if it's --
25   Q    Is that true, Doctor?  What would make 
0123
 1   you suspicious for an error in the labs is 
 2   -- is that the degree of bandemia is so high 
 3   that you would suspect error, true? 
 4             MR. SCHOBERT:   Objection. 
 5             THE WITNESS:   It doesn't go with 
 6   -- with the white count of 4.6.
 7   BY MR. JACOBSON:
 8   Q    Is my statement an accurate statement, 
 9   Doctor? 
10             MR. SCHOBERT:   Objection.  He 
11   answered it.  Go ahead. 
12             THE WITNESS:   No, I -- the 
13   question was what, again? 
14   BY MR. JACOBSON:
15   Q    Is the degree of bandemia so high on 
16   the 11:30 labs that you would suspect it was 
17   erroneous?  Is that a true statement?
18   A    I mean, so -- it's abnormal, so I would 
19   want to know if it's truly abnormal.  I 
20   don't know what "so high" means.
21   Q    Well, Doctor, if the bands were 18, 
22   would you suspect that the labs were 
23   erroneous?
24   A    I would consider that normal.
25   Q    Okay.
0124
 1   A    With the clinical -- with the clinical 
 2   picture and a normal white count --
 3             MR. SCHOBERT:   Wait.  He's not 
 4   done. 
 5             THE WITNESS:   With the white 
 6   count of 4.6, and they were 18, I would say 
 7   it's normal.
 8   BY MR. JACOBSON:
 9   Q    If they were 22, Doctor, would you 
10   consider that erroneous or potentially 
11   erroneous?
12   A    Possibly.
13   Q    When you say one in five labs comes 
14   back incorrect, what do you mean by that?
15   A    That, you know, you don't -- you don't 
16   -- we treat the residents not to treat based 
17   on labs because one out of every five labs 
18   will come back abnormal.  You may get a 
19   calcium, and it will be reported as abnormal 
20   when it truly is normal. 
21   Q    And why is that?  What -- what causes 
22   the labs to be abnormal?
23   A    There's numerous reasons.  One is 
24   what's given as abnormal may not be truly 
25   abnormal in a patient who's postpartum.  
0125
 1   Two, there's always lab error.  I mean, it's 
 2   dependent on people doing the test.  And, 
 3   three, there's a degree of error with 
 4   machines that run the tests.
 5   Q    Is the error in the reading or the -- 
 6   or the recording of the values?
 7   A    I'm sorry? 
 8   Q    In other words, would you suspect that 
 9   the error would be in the -- in the 
10   determination, for example, of the number of 
11   bands or the recording of that? 
12             MR. SCHOBERT:   Objection. 
13             THE WITNESS:   It would be the 
14   determination. 
15   BY MR. JACOBSON:
16   Q    Okay.  Doctor, if the house officer 
17   doesn't feel that the care is appropriate or 
18   feels that -- that the patient needs 
19   antibiotics, does the house officer have the 
20   duty to communicate that to the attending? 
21             MR. SCHOBERT:   Objection.  Go 
22   ahead. 
23             THE WITNESS:   The house officer's 
24   responsibility is to report to the 
25   attending.  He's not there to make 
0126
 1   management decisions.  So --
 2   BY MR. JACOBSON:
 3   Q    Does the house officer have a duty to 
 4   exercise his own independent judgment in the 
 5   care of a patient?
 6   A    As defined by what a house officer 
 7   does, no.  He's there for a specific task.  
 8   If they ask him to do a pelvic exam, they do 
 9   a pelvic exam.
10   Q    Okay.  So, if Dr. Hsieh had a suspicion 
11   that this patient had an infection, he need 
12   not communicate it to Dr. Hahn, correct?
13   A    Not directly.  He -- somebody needs to 
14   notify him that there's -- there's a 
15   possibility of that. 
16   Q    Well, if Dr. Hahn doesn't feel that the 
17   patient's -- patient is getting appropriate 
18   care for an infection or anything else --
19             MR. SCHOBERT:   Dr. Hsieh.
20   BY MR. JACOBSON:
21   Q    Pardon me.  If Dr. Hsieh doesn't feel 
22   that the patient is getting appropriate care 
23   for an infection or any other condition, 
24   does he have a duty to the patient to ensure 
25   that his opinions are relayed to Dr. Hahn 
0127
 1   either directly or indirectly? 
 2             MR. SCHOBERT:   Objection. 
 3             THE WITNESS:   I would say that he 
 4   should notify him of the abnormal values.
 5   BY MR. JACOBSON:
 6   Q    So, if Dr. Hahn does feel that the 
 7   patient is not getting appropriate care --
 8             MR. JEFFERS:   You mean Dr. Hsieh? 
 9   BY MR. JACOBSON:
10   Q    I'm sorry.  If Dr. Hsieh does not feel 
11   that the patient -- patient is being cared 
12   for appropriately, he does have a duty to 
13   ensure that Dr. Hahn knows that? 
14             MR. SCHOBERT:   Objection.  That's 
15   not what he said.
16   BY MR. JACOBSON:
17   Q    Is that correct?  Well --
18   A    Everybody has different opinions.  His 
19   job is to notify him of any abnormality, and 
20   then Dr. Hahn is in charge of his 
21   management. 
22   Q    You've made yourself clear in that, 
23   Doctor.  What I want to know is, if Dr. 
24   Hsieh arrives at his own conclusion that the 
25   patient needs something else for appropriate 
0128
 1   care, and she's not getting it, does he have 
 2   a duty to make sure that Dr. Hahn is aware 
 3   of his feeling, or can he just disregard 
 4   that? 
 5             MR. SCHOBERT:   Objection.  Asked 
 6   and answered five times. 
 7   BY MR. JACOBSON:
 8   Q    Doctor? 
 9   A    Everybody has their own opinion.  His 
10   job is to notify Dr. Hahn of what the 
11   abnormal values are, and then Dr. Hahn makes 
12   his decision. 
13   Q    And if Dr. Hahn's decision is 
14   inadequate by Dr. Hsieh's opinion, he need 
15   not follow that up?  He could just rely on 
16   Dr. Hahn?
17   A    It's Dr. Hahn's patient. 
18   Q    I'm correct in that regard, right?
19   A    It's Dr. Hahn's patient.  So, Dr. Hahn 
20   would make the decision. 
21   Q    In other words, Dr. Hsieh doesn't need, 
22   even if he feels that Dr. Hahn is not doing 
23   the right thing, he doesn't need to tell 
24   that to Dr. Hahn as long as Dr. Hahn is 
25   informed of --
0129
 1   A    Is appropriately informed, yes, you 
 2   know.
 3   Q    Dr. Hsieh has discharged his 
 4   responsibility. 
 5   A    Correct. 
 6   Q    Now, certainly Dr. Hsieh as a Board 
 7   certified obstetrician should know how to 
 8   diagnose and treat postpartum infection, 
 9   correct? 
10             MR. SCHOBERT:   Objection. 
11             THE WITNESS:   I think in his job 
12   as a house officer his -- his duty was to 
13   perform the tasks asked of him. 
14   BY MR. JACOBSON:
15   Q    But -- but in terms of his abilities as 
16   a Board certified obstetrician, you would 
17   expect him to know how to diagnose and treat 
18   postpartum infection, correct?
19   A    That's what the definition the board 
20   gives, yes.
21   Q    All right.  Doctor, when one is 
22   attempting to evaluate a bleed, would it be 
23   incumbent on the physician to look at, 
24   amongst other things, the platelet count?    
25             MR. SCHOBERT:  I'm sorry.  I -- I 
0130
 1   lost track.  You asked about a bleed; is 
 2   that what you said? 
 3             MR. JACOBSON:  Yes, yes. 
 4             MR. JEFFERS:   Ask it again. 
 5             MR. SCHOBERT:   I apologize.
 6   BY MR. JACOBSON:
 7   Q    When a physician is attempting to 
 8   determine whether or not the patient is 
 9   bleeding --
10   A    Uh-huh.
11   Q    -- would the platelets be one of the 
12   lab values that you would have to look at?
13   A    It can be, yes. 
14   Q    Is it, indeed, one of the lab values, 
15   Doctor, which can give you useful 
16   information about whether the patient has a 
17   bleed or not?
18   A    In -- in this patient, it -- it could 
19   help.  She was pre-eclamptic, and we know 
20   her platelets were low. 
21             MR. JEFFERS:   Bill, I'm sorry.  I 
22   missed -- are you talking the WBC now? 
23             MR.JACOBSON:   No, he's talking 
24   about the platelets.  
25   BY MR. JACOBSON:
0131
 1   Q    Basically, Doctor, forget about this 
 2   patient.  If a physician is -- is concerned 
 3   that a patient might have a bleed, then that 
 4   physician should look at, amongst other 
 5   things, the platelet count, true? 
 6             MR. SCHOBERT:   Objection. 
 7             THE WITNESS:   It's one of the 
 8   things that he can look at, yes. 
 9   BY MR. JACOBSON:
10   Q    It's one of the things they should look 
11   at, correct?
12             MR. SCHOBERT:   Objection. 
13             THE WITNESS:   It depends on the 
14   patient's scenario.
15   BY MR. JACOBSON:
16   Q    Doctor, you would have looked at the 
17   platelets for this patient, correct? 
18             MR. JEFFERS:   Objection. 
19   BY MR. JACOBSON:
20   Q    At 12:30, if you were asked as a house 
21   officer to evaluate for a bleed, would you 
22   look at the platelets? 
23             MR. SCHOBERT:   Objection. 
24             THE WITNESS:   In -- in a 
25   pre-eclamptic patient, yes. 
0132
 1   BY MR. JACOBSON:
 2   Q    Why -- why -- why particularly so in a 
 3   pre-eclamptic patient, Doctor?
 4   A    Well, I mean, just because she's 
 5   delivered, the preeclampsia can continue, 
 6   and if it drops to a certain level, it could 
 7   lead to bleeding.
 8   Q    Doctor, when -- when in this -- when in 
 9   your opinion did this patient become septic? 
10             MR. SCHOBERT:   This patient? 
11             MR. JACOBSON:   Yes. 
12             MR. SCHOBERT:   Okay.  All right. 
13             THE WITNESS:   Probably the 
14   morning of the 26th.
15   BY MR. JACOBSON:
16   Q    About what time?
17   A    7:45 when she started with the mental 
18   status change.
19   Q    How about, Doctor, when the blood 
20   pressures dropped in the -- at around 2:15 
21   a.m.; would that be a reasonable starting 
22   point for the sepsis?
23   A    Prospectively or retrospectively? 
24   Q    Retrospectively. 
25             MR. JEFFERS:   Objection. 
0133
 1             MR. SCHOBERT:   Object.  Go ahead. 
 2             THE WITNESS:   Retrospectively, 
 3   possibly. 
 4   BY MR. JACOBSON:
 5   Q    Doctor, if -- if this was your patient 
 6   at 2:15 a.m. with the blood pressures 
 7   dropping, and assuming you knew of all the 
 8   labs --
 9   A    Okay.
10   Q    Okay?  You knew the entire picture and 
11   the blood pressure dropping, would you be 
12   concerned about sepsis? 
13             MR. JEFFERS:   Objection.
14             MR. SCHOBERT:   At 2:15? 
15             MR. JACOBSON:   Yeah, at 2:15.
16             MR. SCHOBERT:   I'm going to 
17   object, but go ahead. 
18             MR. JEFFERS:   Object.
19             THE WITNESS:   I'm sorry? 
20   BY MR. JACOBSON:
21   Q    Assuming you knew all the labs and the 
22   blood pressures of 100 over 44, 88 over 53, 
23   120 over 60 and the rest of the patient's 
24   picture, would you be concerned about 
25   sepsis? 
0134
 1             MR. JEFFERS:   Object.
 2             MR. SCHOBERT:   I'm going to 
 3   object, but go ahead.  
 4             MR. LEAK:      Object. 
 5             THE WITNESS:   Retrospectively, 
 6   it would be a thought, yes.
 7   BY MR. JACOBSON:
 8   Q    Well, no, I'm talking about 
 9   prospectively now.  This is your patient.  
10   It's 2:15 a.m., and you know of all the 
11   labs.  You know of the left shift, and let's 
12   assume it's an accurate left shift.  You 
13   know of the patient's restlessness and 
14   anxiety, and you know of the patient's urine 
15   output, temperature, pulse rate, uterine 
16   cramping.  When the blood pressures are 
17   dropping at 2:15 a.m. to 100 over 44, 88 
18   over 53 and 120 over 60, would you be 
19   concerned about sepsis? 
20             MR. SCHOBERT:   Objection.  Go 
21   ahead. 
22             THE WITNESS:   Based on that 
23   scenario, my first thought would be that 
24   this is related to the hemorrhage or the 
25   preeclampsia.
0135
 1   BY MR. JACOBSON:
 2   Q    Would you consider, Doctor, sepsis in 
 3   your differential at that point?
 4   A    I would consider an infection, not 
 5   necessarily sepsis.
 6   Q    Okay.  Now, Doctor, when the -- at 
 7   around 4:10 A.M., the blood pressure is 
 8   reported as 90 over 49.  Would you be 
 9   concerned -- pardon me.  At 4:05 a.m. the 
10   blood pressure is 95 over 50.  At 4:10 the 
11   blood pressure is 90 over 49.  At 4:15 the 
12   blood pressure is 98 over 60, at 4:20 one 
13   over four -- pardon me, 104 over 46.  
14   Doctor, would you begin to have a higher 
15   suspicion for sepsis at that point? 
16             MR. SCHOBERT:   Again, this is 
17   assuming everything else up to that point 
18   prospectively.
19   BY MR. JACOBSON:
20   Q    Assuming you know everything. 
21             MR. SCHOBERT:   All right.  I'll 
22   object, but go ahead. 
23             THE WITNESS:   It can go along 
24   with it, but my -- at this -- in this 
25   situation, the most likely thing is that 
0136
 1   she's dehydrated, and she's falling.
 2   BY MR. JACOBSON:
 3   Q    Doctor, assuming that you're there at 
 4   bedside at 4:15, and you know everything 
 5   there is to know in terms of the labs and 
 6   the presentation of the patient up to this 
 7   point, and you see her blood pressure 
 8   falling, Doctor, Doctor, you would have some 
 9   suspicion for sepsis, correct? 
10   A    For an infectious process, yes.
11   Q    And, Doctor, at this point would you 
12   then discontinue the mag sulfate?
13   A    No.
14   Q    Why not?
15   A    She's still at significant risk for 
16   seizure in light of her liver enzymes going 
17   up.  You can't tell whether her preeclampsia 
18   is getting worse.
19   Q    If, indeed, Doctor, the patient is -- 
20   is going into shock, you would want to 
21   discontinue the mag sulfate, correct?
22   A    No.  For -- for what -- for what 
23   reason?
24   Q    Well -- 
25   A    It has no effect on blood pressure or a 
0137
 1   minimal effect.  It may drop -- drop it 
 2   maybe two or three millimeters of mercury.
 3   Q    How about respiratory rate; will it 
 4   tend to depress the respiratory rate?
 5   A    Only if it's at a toxic level over 14.
 6   Q    How about Ativan, Doctor?  If you had a 
 7   patient you were concerned was going into 
 8   shock, would you give them Ativan?
 9   A    For the  --
10             MR. SCHOBERT:   That's a 
11   hypothetical, going into shock, give them 
12   Ativan. 
13             MR. JACOBSON:  Yeah.
14             THE WITNESS:   No, if you tell me 
15   they're in shock, you don't give them 
16   anything to relax them, no. 
17   BY MR. JACOBSON:
18   Q    In other words, giving Ativan when a 
19   patient is -- is in shock or going into 
20   shock could worsen the problem, correct?
21   A    Yes, if they're in shock, it could 
22   sedate them, yes. 
23   Q    Doctor, the -- the one patient that you 
24   had with toxic shock that you said you were 
25   peripherally involved in, did that patient 
0138
 1   survive?
 2   A    Yes, I believe so. 
 3   Q    Was that a patient in the puerperal 
 4   period?
 5   A    It was the perinatal period, within the 
 6   first 12 hours.
 7   Q    Okay, and that case was a case where 
 8   there was a confirmation of toxins, correct? 
 9   That was a toxic shock-like syndrome case, 
10   correct?
11   A    As -- as far as I can remember, yes.
12   Q    Streptococcal?
13   A    Yes. 
14   Q    Doctor, the literature search that you 
15   did, was that literature search drawn from 
16   one particular body of literature, the 
17   obstetrical literature, or was it from all 
18   the literature?
19   A    It's all available literature on Med -- 
20   Medline.
21   Q    Okay, and the statistics that -- that 
22   you found and that you quote in your report 
23   is that mortality in between 30 to 60 
24   percent and, in other words, that would mean 
25   the survival would be between 40 to 70 
0139
 1   percent, correct?
 2   A    Right, if you do the math, yes. 
 3   Q    Doctor, did you read Nurse Prokop's 
 4   deposition before you wrote your report?
 5   A    No, I did not. 
 6   Q    Why not?
 7   A    I had no depositions available.  I 
 8   don't think they'd been done when I did my 
 9   report. 
10             MR. SCHOBERT:   All right.  The 
11   kibbitzing rules come into effect at three 
12   hours. 
13   BY MR. JACOBSON:
14   Q    Doctor, retrospectively, when did this 
15   patient get an infection? 
16             MR. JEFFERS:   Objection. 
17             THE WITNESS:   Well, 
18   retrospectively, the best -- I -- I don't 
19   know.  It -- it could have been before she 
20   went into labor.  It could have been during 
21   labor or after. 
22   BY MR. JACOBSON:
23   Q    Retrospectively, when were the first 
24   signs and symptoms of infection? 
25             MR. JEFFERS:   Object. 
0140
 1             THE WITNESS:   Well, based on 
 2   retrospectively looking at this case, 
 3   probably the 25th at 1925. 
 4   BY MR. JACOBSON:
 5   Q    Okay. 
 6   A    With the temperature. 
 7   Q    Now, retrospectively, Doctor -- 
 8             MR. JEFFERS:   What? 
 9             THE WITNESS:   1925 on the 25th.
10   BY MR. JACOBSON:
11   Q    Retrospectively, Doctor, when did she 
12   become septic?
13                  MR. JEFFERS:   Object.
14             THE WITNESS:   7:45 on the 26th.  
15   BY MR. JACOBSON:
16   Q    Okay, and why -- why is that, Doctor?
17   A    The -- usually the first sign of sepsis 
18   is a mental status change, and that's when 
19   she exhibited that.
20   Q    And, retrospectively, when did she go 
21   into shock?
22             MR. JEFFERS:   Objection
23             MR. SCHOBERT:   I thought you just 
24   asked him that.
25             MR.JACOBSON:   No, sepsis, yeah. 
0141
 1             MR. SCHOBERT:  Sepsis.
 2             THE WITNESS:   When she went into 
 3   shock, I would have to say it's after that. 
 4             MR. SCHOBERT:   I'm sorry. 
 5   BY MR. JACOBSON:
 6   Q    Do you know when, Doctor? 
 7             MR. SCHOBERT:   Object.  Go ahead. 
 8             THE WITNESS:   She went into 
 9   shock? 
10   Q    Yeah. 
11   A    Later that morning. 
12             MR.JACOBSON:   That's all I have. 
13             MR. SCHOBERT:   Doug? 
14             MR. LEAK:       Doctor, I'm here 
15   on behalf of Dr. Hahn, and it's fair to say 
16   that you will not be rendering any opinions 
17   relative to his care and treatment? 
18             THE WITNESS:   Correct.  
19             MR. LEAK:       Thank you.  That's 
20   all I have. 
21             MR. JEFFERS:   Is that similarly 
22   true relative to the nurses? 
23             THE WITNESS:   Correct. 
24             MR. JEFFERS:   Thank you.
25             MR. JACOBSON:   Well I intend -- 
0142
 1   just for the record, I intend to ask him his 
 2   opinions, whether you ask him to give them 
 3   or not.
 4             MR. JEFFERS:   You can do whatever 
 5   you want to do. 
 6   BY MR. JACOBSON:
 7   Q    Doctor, have we discussed all your 
 8   opinions in this case?
 9   A    Yes. 
10             MR. JACOBSON:   Thank you, Doctor.
11             (Off the videotape.)
12             MR. SCHOBERT:   Doctor, you have 
13   the right to review the transcript, and I 
14   would ask that you exercise that right to  
15   review the transcript.  I'll get you a copy 
16   of the tape and transcript for your review.  
17   Tell her you do not waive signature.  Just 
18   say:  I do not waive signature.
19             THE WITNESS:   Oh, okay. 
20             MR. SCHOBERT:   He says he doesn't 
21   waive. 
22   
23   
24                 - - - o0o - - 
25   
0143
 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, ROBERT FLORA, M.D., 
 8   was by me first duly sworn to testify to the 
 9   truth, the whole truth and nothing but the 
10   truth in the case aforesaid; that the 
11   testimony then given by the above-referenced 
12   witness was by me reduced to stenotypy in 
13   the presence of said witness; afterwards 
14   transcribed; and that the foregoing is a 
15   true and correct transcription of the 
16   testimony so given by the above-referenced 
17   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.
0144
 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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