1 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 4 5 G. DELORES SAVAGE, as Legally ) CASE NO. 374280 Appointed Guardian for ) 6 WANDA WRIGHT, an Incompetent, ) et al., ) 7 ) DEPOSITION OF Plaintiffs, ) 8 ) PAUL D. GATEWOOD, M.D. versus ) 9 ) COLUMBIA/HCA HEALTHCARE, ) 10 et al., ) ) 11 Defendants. ) 12 13 - - - - - - - 14 15 Deposition of PAUL D. GATEWOOD, M.D., a Witness 16 herein, called by the Plaintiffs for Cross-Examination 17 pursuant to the Ohio Rules of Civil Procedure, taken 18 by the undersigned, Linda McAnallen, a Stenographic 19 Reporter and Notary Public in and for the State of 20 Ohio, at the Oberlin Inn, 7 North Main Street, Oberlin, 21 Ohio, on October 27, 2000, at 4:00 p.m. 22 23 - - - - - - - 24 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418 2 1 APPEARANCES: 2 On Behalf of the Plaintiffs: 3 Tobias J. Hirshman, Attorney at Law 4 Linton & Hirshman Hoyt Block Suite 300 5 700 West St. Clair Avenue Cleveland, Ohio 44113-1230 6 7 On Behalf of the Defendants Dr. Liu, Nurse-Midwife Nuza, and Dr. Gyves: 8 Alan B. Parker, Attorney at Law 9 Reminger & Reminger The 113 St. Clair Building 10 Cleveland, Ohio 44114-1273 11 On Behalf of the Defendants Columbia/HCA 12 Healthcare and B. J. Burton, R.N. (by telephone): 13 Mark D. Frasure, Attorney at Law Buckingham, Doolittle & Burroughs 14 4518 Fulton Drive, N.W. Canton, Ohio 44718 15 16 - - - - - - - 17 18 19 20 21 22 23 24 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418 3 1 I N D E X 2 EXAMINATION BY PAGE 3 Mr. Parker 4, 81 4 Mr. Frasure 58, 85 5 6 DEFENDANT'S EXHIBITS PAGE 7 A, Dr. Gatewood's Report 10 8 B, Handwritten Notes, one page 11 9 C, Handwritten Notes, one page 12 10 D, Handwritten Notes, one page 14 11 E, Handwritten Notes, one page 14 12 F, Handwritten Notes, one page 14 13 G, Handwritten Notes, one page 20 14 H, Handwritten Notes, one page 20 15 I, Handwritten Notes, one page 20 16 J, Handwritten Notes, one page 20 17 K, Handwritten Notes, one page 21 18 L, Handwritten Notes, one page 21 19 20 PLAINTIFF'S EXHIBITS 21 None 22 23 - - - - - - - 24 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418 4 1 (Defendant's Deposition Exhibit A, 2 Dr. Gatewood's report, and Exhibits B 3 through L, Dr. Gatewood's handwritten notes, 4 were marked for identification.) 5 WHEREUPON, 6 PAUL D. GATEWOOD, M.D., 7 after being first duly sworn, as hereinafter 8 certified, testified as follows: 9 CROSS-EXAMINATION 10 BY MR. PARKER: 11 Q. Dr. Gatewood, my name is Alan Parker. I'm 12 privileged to be an attorney representing Dr. Liu, 13 Certified Nurse-Midwife Nuza, and Dr. Gyves in 14 this case. You've had your deposition taken 15 before? 16 A. Yes, sir. 17 Q. So you know that I'll be asking questions. If my 18 questions are confusing or don't make sense, let 19 me know, and I'll try again. Okay? 20 A. Sure. 21 Q. Will you please state your name for the record? 22 A. My name is Paul Douglas Gatewood, M.D. 23 Q. And in what field of medicine do you practice? 24 A. I'm an obstetrician/gynecologist. 25 Q. Do you have any particular areas of specialty? PREMIER COURT REPORTING 330-494-4990 888-440-1418 5 1 A. My special interest is infertility microsurgery, 2 but I am not boarded in a subspecialty. 3 Q. Are you board certified? 4 A. Yes, sir, I am. 5 Q. And when did you become board certified? 6 A. I became board certified in 1976. 7 Q. And do you have any specialty certifications? 8 A. No, sir. 9 Q. In what states are you licensed to practice 10 medicine? 11 A. I should qualify that. Of course, my boards are 12 in obstetrics and gynecology. 13 Q. Sure. 14 A. I have no subspecialty. 15 Q. Okay. 16 A. I'm licensed in the State of Ohio. 17 Q. You did not bring a C.V. with you. Can you very 18 briefly give me a summary of your medical 19 education and the positions that you've held up to 20 the present time? 21 A. Sure. I graduated from West Virginia University 22 School of Medicine with honors in 1970. I did a 23 four-year residency in obstetrics and gynecology 24 at Akron City Hospital, Akron, Ohio, from 1970 25 through 1974. In 1972 as part of my second-year PREMIER COURT REPORTING 330-494-4990 888-440-1418 6 1 rotation I was privileged to serve as a Gallaway 2 fellow for two months at the Sloan-Kettering 3 Memorial Hospital in New York City in gynecologic 4 oncology. At the completion of my residency, I 5 took and successfully passed part one of my 6 boards. I went into the private practice of 7 obstetrics and gynecology in Akron, Ohio, July the 8 1st of 1974. In 1975-76 -- I forget the date 9 right offhand -- I took my training in gynecologic 10 microsurgery, infertility microsurgery, at the 11 Ralph Davis Institute of Microsurgical Research in 12 San Francisco, California. I took my boards and 13 successfully passed the oral portion in November 14 of 1976. I was on the teaching service at Akron 15 City Hospital from 1974 until I relocated to 16 Oberlin in March of 1999. I was an assistant 17 clinical professor of obstetrics and gynecology at 18 the Northeastern Ohio Universities College of 19 Medicine. I also had privileges at Akron General 20 Medical Center as well as Akron -- it's now called 21 the Summa Health System, Akron City Hospital and 22 St. Thomas. The majority of my practice was at 23 Akron City Hospital. 24 Q. Currently where do you practice? 25 A. Currently I am the chairman of the department of PREMIER COURT REPORTING 330-494-4990 888-440-1418 7 1 obstetrics and gynecology at the Oberlin Medical 2 Center here in Oberlin, Ohio. 3 Q. Is the Oberlin Medical Center an inpatient 4 facility? 5 A. Yes, sir. 6 Q. Are you an employee of the Oberlin Medical Center? 7 A. I am an employee of the -- There is a physician 8 division of the Oberlin Medical Center. Allen 9 Memorial Physicians I believe is the name of the 10 employment contract that I have, which is under 11 the auspices or the umbrella of the Oberlin 12 Medical Center. It used to be Allen Memorial 13 Hospital and the Oberlin Clinic, and they merged 14 in February of this year. 15 Q. You told me that you're the chairman of the 16 department of obstetrics and gynecology. 17 A. That's correct. 18 Q. How many people are in that department? 19 A. Not very many. We probably have a total of eight 20 or nine OB/GYNs on staff, of which two are members 21 of the -- my partner and I are members of the 22 Oberlin Medical Center staff. The rest are in 23 private practice. 24 Q. How would you describe the type of practice that 25 you engage in? PREMIER COURT REPORTING 330-494-4990 888-440-1418 8 1 A. My practice now is pretty much fifty-fifty 2 obstetrics and gynecology. When I was in practice 3 in Akron, Ohio, I had a rather substantial 4 infertility practice for many years. I'm trying 5 to redevelop a referral system up here. I do some 6 infertility, I've done some microsurgery work, but 7 I don't think it's sufficient to take a large 8 percentage so I basically call it 50/50. 9 Q. When you were in Akron, what percentage of your 10 practice dealt with infertility issues as opposed 11 to obstetrical or general gynecologic practice? 12 A. At its maximum, it would have been maybe a third. 13 It would have been a third OB, a third GYN and a 14 third infertility. As I got older, I was reducing 15 my obstetrics, and so my GYN probably was more 16 than 50 percent in the last two or three years I 17 was there. 18 Q. We have a variety of materials here on the table. 19 Do they constitute your file on this case? 20 A. That's correct. 21 Q. Do you have anything else that's a part of the 22 file of this case that you didn't bring? 23 A. No, sir. 24 Q. It appears to me -- and if you want to run through 25 it, that's fine, but otherwise I'll run through it PREMIER COURT REPORTING 330-494-4990 888-440-1418 9 1 for brevity's sake. 2 A. Go right ahead. 3 Q. It appears to me that the bulk of these materials 4 are the hospital records from St. Luke's. 5 A. Yes. And that includes the prenatal records for 6 the patient, which is a small segment of this 7 obviously. 8 Q. And as I looked at it quickly, you didn't have 9 other medical records, for instance after 10 Mrs. Wright went into a vegetative state and was 11 cared for at other institutions? You don't have 12 those records? 13 A. I have seen none of those. 14 Q. Okay. Fair enough. So other materials that are 15 part of your file are some depositions? 16 A. That's correct, sir. 17 Q. And for the purpose of the record, I'll read 18 quickly what depositions you brought with you. 19 Dr. Liu, Janice Terry. 20 MR. HIRSHMAN: Who? 21 MR. PARKER: Janice Terry. 22 THE WITNESS: That's one of the sisters. 23 Q. Delores Savage, Desiree Marsh, Deborah Amerson, 24 Judith Nuza, and it appears as though there are 25 two volumes of that, and Michael Gyves, M.D., and PREMIER COURT REPORTING 330-494-4990 888-440-1418 10 1 Nurse Burton. 2 Are there any other depositions that you 3 have reviewed in connection with this case? 4 A. Did you say Dr. Gyves? 5 Q. Yes. 6 A. Okay. 7 MR. HIRSHMAN: Did you say Liu? 8 MR. PARKER: Yes. 9 A. Then that's it, I believe. 10 Q. Have you reviewed all of these depositions or are 11 there some that you determined weren't relevant 12 and you have in your file but you did not -- 13 A. No, I read them all. 14 Q. Have you reviewed any other materials in 15 connection with this case? 16 A. No, sir. 17 Q. Have you reviewed any medical literature in 18 connection with this case? 19 A. Specifically for this case, no, sir. 20 Q. Additionally you provided me with some handwritten 21 notes. Actually before I go with the notes, you 22 generated a handwritten report; is that correct? 23 A. That is correct. 24 Q. Showing you what has been marked as Defendant's 25 Exhibit A, is that a copy of your report? PREMIER COURT REPORTING 330-494-4990 888-440-1418 11 1 A. I believe so, yes, sir. 2 Q. It appears to be dated May 18, 2000? 3 A. That's correct. 4 Q. Is this the only report that you have authored in 5 connection with this case? 6 A. I believe so. 7 Q. Did you circulate any drafts of this report? 8 A. No, this is it. 9 Q. You also provided us today with a number of 10 handwritten notes, and I have had them identified 11 as Defendant's Exhibits B through L. I'm going to 12 hand those to you. Of course, you have the 13 originals before you. If you could just tell me, 14 what are these notes of? That's what I'm 15 interested in at this point. What is Exhibit B? 16 A. Exhibit B are notes that I made in reference to 17 the deposition of Desiree Marsh. 18 Now, when I make these notes, I'm 19 basically copying down and giving page number 20 references to statements that were made. These 21 generally do not contain my opinions or 22 editorials. 23 Q. You answered what my question was going to be. I 24 was wondering if the numbers at the beginning of 25 lines correlated to page numbers. PREMIER COURT REPORTING 330-494-4990 888-440-1418 12 1 A. That's correct. 2 Q. So essentially these are highlights and 3 references, kind of an index to things that were 4 pertinent to you about Ms. Marsh's deposition 5 testimony? 6 A. Correct. It allows me to do a rapid scan of what 7 I thought was pertinent material brought out 8 during the depositions. 9 Q. Okay. Now, what is Exhibit C? 10 A. Exhibit C is a list of deviations of Dr. Liu that 11 I made up in my final review, and this may have -- 12 I may have misquoted. This may have been done at 13 the time I did the letter. 14 Q. That's what I was about to ask you. 15 A. These were notes that I used to compose the 16 letter. 17 Q. That's what I was about to ask you. Did this 18 predate the report, Exhibit A, or is this 19 something that you prepared after the report, 20 Exhibit A, or were they essentially 21 contemporaneous? 22 A. Most of it would have been contemporaneous. 23 Q. And you say most of it. Are there portions 24 that -- 25 A. If you see the dark areas, in my review in PREMIER COURT REPORTING 330-494-4990 888-440-1418 13 1 preparation for this I thought I would add when 2 they had the blood pressures that I noted at the 3 times that the pulses were approximately in the 4 60s. And when they had the labs, I wrote out what 5 the labs were, the AST and the ALT. 6 Q. There's also a marginal note. When was that made? 7 I don't know if I can read it. Referral never -- 8 A. Refused nurse request to come in, called at 04:45, 9 arrived at 05:29. 10 According to the deposition of Nurse Nuza, 11 she asked the nurse to call Dr. Liu to come in 12 because of the bradycardia, and he would not do 13 that until he talked to the midwife. 14 Q. When was that notation, that marginal notation 15 made? 16 A. Last night I believe. The comments that are in 17 dark, the pulse and the liver function tests and 18 the note to the side were made last night. The 19 rest of this was made at the time I believe that I 20 wrote the letter, because these things I do not 21 believe are incorporated in the letter. 22 Q. What things are not incorporated in the letter? 23 A. Well, the specifics like what is AST, what is ALT; 24 when the labs came back, which ones were elevated, 25 the AST or ALT. I think I said that the labs were PREMIER COURT REPORTING 330-494-4990 888-440-1418 14 1 elevated but I didn't spell them out, and I did 2 not make notation of the pulse being in the 60s in 3 conjunction with the blood pressures. 4 Q. Exhibit D, what are we looking at here? 5 A. Exhibit D is the first page of three pages of 6 notes in reference to the deposition of Dr. Liu. 7 So that would be Exhibits D, E and F. 8 Q. I notice on Exhibit F that again we have some dark 9 entries? 10 A. Right. 11 Q. Were those contemporaneous with the making of this 12 document or is that something you've added 13 recently? 14 A. These are things that I may have added last night. 15 If it's dark compared to the rest of it, it was 16 something added last night. 17 Q. Can you read to me that marginal notation? It 18 looks like 141 or 147. 19 A. Yes, he stated the liver ruptured when the baby's 20 heartbeat dropped. 21 Q. Was that of particular significance to you when 22 you reviewed the case last night? 23 A. Well, yes, in case the question comes up when did 24 the liver actually rupture. Well, his opinion was 25 the liver ruptured at the time of the baby's PREMIER COURT REPORTING 330-494-4990 888-440-1418 15 1 heartbeat dropping. 2 Q. Do you have an opinion on that issue? 3 A. Yes, I do. 4 Q. What is your opinion as to when the liver 5 ruptured? 6 A. I think in all probability the actual rupture 7 occurred at the time the fetal heart rate dropped. 8 There was periportal hemorrhage that was 9 occurring. You won't get elevated liver enzymes 10 unless you have periportal hemorrhage and cellular 11 necrosis. That was occurring on admission. We 12 did not have the beginning of bleeding significant 13 enough to stretch the liver capsule until 14 approximately 3:45 in the morning. And then at 15 4:15 is when the fetal heart rate started to 16 crash. Now, these are within a minute or two. 17 I'm just giving an overview. 18 So in my opinion the beginning of bleeding 19 into the capsule, which was distending the hepatic 20 capsule called Glisson's capsule, began at the 21 time that she was complaining and moving around in 22 the bed uncomfortable of the shoulder pain. And 23 that was documented I believe around 3:45 in the 24 morning. 25 The rupture itself with the bleeding into PREMIER COURT REPORTING 330-494-4990 888-440-1418 16 1 the peritoneal cavity occurred in my opinion 2 around the time that the fetal heart crashed down. 3 Because under these circumstances, if you look, 4 the baby's heartbeats were coming along at a 5 fairly decent rate with accelerations. There was 6 no evidence that this baby was in distress at the 7 time. 8 And the other thing that's significant -- 9 and that's why I wrote them in, because I was 10 putting all this together last night. When the 11 patient had the markedly elevated pressures, which 12 was throughout, her pulse rates were normal. But 13 when she ended up having her surgery, her pulse 14 rates started to skyrocket. That's when she was 15 going into shock. She was not having active and 16 severe bleeding initially, because otherwise she 17 would have manifested with an increase in her 18 pulse, and that did not occur until the very end. 19 So I agree with him on that aspect, that the liver 20 in all probability ruptured around the time -- I 21 can't give you the exact minute, I don't think 22 anyone can, but ruptured with significant enough 23 blood loss that the fetal heart started to be 24 compromised. And that can occur over a rather 25 short period of time. So significant enough PREMIER COURT REPORTING 330-494-4990 888-440-1418 17 1 bleeding to distend the capsule at 3:45, 2 significant bleeding probably with leaking or 3 rupture at around 4:15 to 4:20, which was 4 obviously found at the time of surgery. 5 Q. And when did Mrs. Wright go into a significant 6 hemodynamic change? 7 A. Well, remember, at around 4:05 after they had 8 called Dr. Liu -- or 5:05, I'm sorry, she seemed 9 to have a change in her affect that she was not as 10 alert as she was before, and I think that probably 11 represented a manifestation of the bleeding at 12 that point. 13 Unfortunately, we don't have a blood 14 pressure cuff machine that would have given you 15 the printout as to what was going on with her 16 pressure and her pulse. Unfortunately, the nurses 17 only took them once an hour, which was totally 18 inadequate. 19 But her change of demeanor and her level 20 of consciousness and awareness seemed to occur 21 around ten after five. And I think that was a 22 representation at that point of the beginning of a 23 significant enough blood loss that she was losing 24 cerebral affect. 25 Q. I think you just answered what I was about to ask. PREMIER COURT REPORTING 330-494-4990 888-440-1418 18 1 It's your opinion that the change in demeanor that 2 happened after 5 a.m. was caused by blood loss? 3 A. Yes, I really do, because I don't think that was a 4 seizure. She never lost consciousness, and they 5 said that she responded again after they talked 6 with her and moved her around I believe on her 7 left side and that. There was no notation 8 whatsoever of specific seizure. And at that point 9 in time, as we know, she was on the mag sulfate, 10 although they did decrease it down, but she had 11 been on the mag, which is for seizure prophylaxis. 12 So I think within a reasonable degree of 13 probability that the change in affect or demeanor 14 was secondary to blood loss and not secondary to 15 cerebral, seizures or something like that. 16 Q. And when you talk about blood loss, you're talking 17 about blood exiting the vascular system? 18 A. Yes, around the liver. The liver fractured. 19 Q. The subcapsular space hadn't yet ruptured at -- 20 A. It reached the point that now it was going to blow 21 out. And when you say that there was 2500 cc. of 22 blood loss from the C-section, they didn't lose 23 that much with the section. And it's interesting, 24 too, that it was also described that there was 25 free blood in clots. So the patient was not into PREMIER COURT REPORTING 330-494-4990 888-440-1418 19 1 a fulminant DIC at that point in time but she had 2 a significant blood loss. She lost half her 3 volume, 2500 cc., in that period of time. And 4 that's enough to make somebody lose some of their 5 cerebral affect. 6 Q. When the liver capsule bled -- I guess ruptured is 7 the word I want to use. When it ruptured, what 8 was the cause of that? 9 A. Pressure. 10 Q. Is it likely that patient movement or trauma or 11 procedure or anything like that played any role in 12 that? 13 A. Not unless you had direct manipulation or 14 movements around the upper abdomen. 15 Q. Such as what? 16 A. Well, someone pushing in on it. To give you a 17 good example -- this might clarify what I'm 18 saying. When you have a patient that you're 19 concerned has a HELLP syndrome, the first thing 20 you do is tell the resident or other people not to 21 keep pushing on the upper quadrants to see if they 22 can feel the liver expanding. You do an 23 ultrasound and see if that's happening, because 24 the pressure of the hand may be sufficient to 25 rupture the capsule. And what's holding the blood PREMIER COURT REPORTING 330-494-4990 888-440-1418 20 1 back and tamponading the bleeding is the capsule, 2 but the stretching of the capsule is what gives 3 you the shoulder pain. So try to leave that 4 alone. And when you have the rupture of the 5 capsule due to the pressure of the build-up of the 6 clot, that's when you're going to have then 7 bleeding going into the abdomen itself. 8 Q. You and I probably have a similar propensity. I 9 go off on tangents listening to your answers, and 10 I think sometimes your answers, in order to 11 explain them to me, take me off of where I was. 12 A. We'll try to keep it keyed in then, because I know 13 you all want to get out of here. Mr. Frasure will 14 tell you, I never give long answers. 15 Q. I sure don't want to cut you off, but I also don't 16 want to go to all these things that I find 17 fascinating and forget to complete the exhibits 18 that I'm trying to identify. 19 A. Sure. 20 Q. So Exhibit G, what is that? 21 A. Exhibits G, H and I represent the notations for 22 the deposition of Judith Nuza, the nurse-midwife. 23 Q. And Exhibit J, what is that? 24 A. Exhibit J is a list of deviations that I compiled 25 for both Judy Nuza and the nurses. PREMIER COURT REPORTING 330-494-4990 888-440-1418 21 1 Q. With respect to Judy Nuza, it looks to me from my 2 photocopy like there are some entries overwritten 3 at a different time than the original entries. Am 4 I correct in that regard? 5 A. In this particular one, no. I wrote those as I 6 was writing the 1's, 2's and 3's, and I tried to 7 put in how that coincided with her deposition. So 8 those were all done at the same time, and you'll 9 see they're in the same ink. 10 Q. This page, Exhibit J, was this made roughly 11 contemporaneously with your report, Exhibit A? 12 A. Probably pretty close to it. 13 Q. And Exhibit K, what is that? 14 A. Exhibit K are the deposition notes I made for the 15 deposition of Nurse Burton. 16 Q. And Exhibit L, what is that? 17 A. Those are notes from the depositions of both 18 Deborah Amerson, R.N., and Michael Gyves, M.D. 19 Q. Now, while it was more work to read your 20 handwriting on your report than it is typewriting, 21 I must admit it was legible. I was able to read 22 your report. It looks to me -- I haven't tried to 23 read Exhibits B through L in the short period of 24 time we've been here, but it looks to me that 25 while I'll probably be able to read it, it may be PREMIER COURT REPORTING 330-494-4990 888-440-1418 22 1 a little more difficult than your report was. Let 2 me ask you this, because I really don't want to 3 make you read this into the record this afternoon. 4 If there are portions I can't read, can I inquire 5 of Mr. Hirshman, and will you work with him just 6 to dictate to him whatever we have questions about 7 if we find we can't read it when we study these? 8 A. Oh, absolutely. 9 Q. Fair enough. Thank you. That avoids us having to 10 do a lot of dictation here this afternoon. 11 A. Sure. 12 Q. HELLP syndrome, what is your understanding of 13 that? What does it mean to you? 14 A. Well, HELLP is an acronym for hemolysis, elevated 15 liver enzymes and low platelets. It's a 16 complication of pregnancy usually associated with 17 pre-eclampsia and is a manifestation of 18 increasingly severe degrees of complications 19 associated with toxemia or pre-eclampsia. Today 20 the term is pregnancy-induced hypertension. 21 Q. Is it separate and distinct from pre-eclampsia or 22 is it a continuum and pre-eclampsia becomes HELLP 23 or -- What can you tell me about that? 24 A. It's not 100 percent. You may have normotensive 25 HELLP syndromes, in other words, the patient PREMIER COURT REPORTING 330-494-4990 888-440-1418 23 1 doesn't have pregnancy-induced hypertension but 2 she has the manifestations of a HELLP syndrome. 3 The majority of HELLP syndrome is 4 associated with a syndrome called toxemia or 5 pre-eclampsia or PIH. The severe manifestation of 6 pre-eclampsia to eclampsia relates to the 7 development of seizures in a patient that had the 8 syndrome of pre-eclampsia. Associated with the 9 seizures may be -- With the severity of the 10 pre-eclampsia you may have indeed the development 11 of a HELLP syndrome in association with that. 12 So it's not 100 percent, but as a general 13 rule as a physician the greater the progression or 14 the greater the severity of the pre-eclampsia, the 15 greater the incidence or the possibility of the 16 development of a HELLP syndrome and other 17 coagulopathies associated with it. 18 Q. In this case did the HELLP syndrome develop from a 19 pre-eclampsic condition or was the HELLP syndrome 20 developing independently? 21 A. I think the two went together. 22 Q. You mentioned in your report that if pre-eclampsia 23 had been stabilized upon presentation at the 24 hospital, the ruptured liver would not have 25 occurred. How is pre-eclampsia treated? PREMIER COURT REPORTING 330-494-4990 888-440-1418 24 1 A. Well, pre-eclampsia, it depends on the severity. 2 I can give you a half-hour dissertation on that, 3 but I don't think you want it. Let's use this 4 case. 5 This case was a severe pre-eclampsia. And 6 the first thing you have to do when you are faced 7 with severe pre-eclampsia is get physician 8 participation at the bedside. You immediately 9 institute magnesium sulfate to try to prevent 10 seizures from occurring or the progression to 11 eclampsia itself. In addition to that, you get 12 the necessary lab work that will assist you in 13 whether or not other complications are occurring 14 such as HELLP. 15 In this situation it was demonstrated that 16 indeed she had HELLP syndrome. The management 17 then is to deliver the baby in the most 18 expeditious way possible depending on the 19 presentation of the patient. And as you know, 20 just for completeness, she had four plus protein 21 with a headache. 22 Now, if you feel that you can stabilize 23 the patient, in other words, control the pressure 24 and you have magnesium and there's no 25 deterioration of her status, namely, headaches do PREMIER COURT REPORTING 330-494-4990 888-440-1418 25 1 not progress getting worse, no seizures, no 2 beginnings of right upper quadrant pain or 3 shoulder pain representing the swelling of 4 Glisson's capsule, then the ideal is to try to 5 deliver the patient vaginally, if they're amenable 6 to induction, if the cervix is ripe. If they're 7 not or if you're in a situation where you have a 8 HELLP syndrome, you have symptoms suggestive of 9 increasing severity, such as blood in the urine, 10 right upper quadrant or shoulder pain, Glisson's 11 capsule stretching, then that means you've got to 12 get the baby out right away, so you do a 13 C-section. And by delivering the placenta, then 14 you start to reverse the process. It doesn't 15 happen immediately. But the treatment is to 16 deliver. 17 Now, when you have a severe manifestation 18 like you did here with all of these corollary 19 problems, one of the things that it's mandatory to 20 do is get that pressure head down, the blood 21 pressure head. And the reason you have to do 22 that, we know that -- We don't know the exact 23 cause of toxemia, so put that to rest. Nobody 24 does. However, we know that we have to control 25 the blood pressure. And one of the reasons for PREMIER COURT REPORTING 330-494-4990 888-440-1418 26 1 that is pre-eclampsia causes spasms of small blood 2 vessels, arterial spasms. And when that happens, 3 you get decreased oxygenation to the target 4 organs, the liver, the brain, the kidney. A 5 manifestation of decreased oxygen is cellular 6 degeneration. So then you get blood in the urine. 7 That tells you that you've got acute tubular 8 necrosis going on in the kidneys. It can tell you 9 also that you may have hemolysis, because you can 10 get blood-tinged looking reddish urine from 11 hemolysis. So that's a significant manifestation 12 of severity. 13 In the liver you have the same process. 14 You have the spasms of the small vessels, you have 15 decreased oxygenation to the tissue in the liver, 16 the hepatocytes, which are arranged in clusters. 17 And so by that, when you have the beginnings of 18 cellular wall breakdown, you release the enzymes 19 in the liver. And those enzymes are the tests 20 that you do. You're testing for elevation of the 21 liver enzymes. And the AST and the ALT are the 22 ones that we test for. When these are markedly 23 elevated, you've got significant hepatocellular 24 damage occurring. Now, that cellular damage, that 25 is not frank bleeding yet. PREMIER COURT REPORTING 330-494-4990 888-440-1418 27 1 So what do we do about the blood pressure? 2 You bring the blood pressure down because you 3 reduce the pressure head of the force of the blood 4 coming through damaged tissue. And if you reduce 5 that force, you reduce the risk of forcing 6 hemorrhage or rupturing of vessels that are 7 already weakened because of hypoxia. That's the 8 reason you want to treat it. That's the reason 9 you've got to get the blood pressure down. If you 10 don't, then what you can do is you can end up with 11 the severe complications that we had here even 12 though these are very rare. 13 Q. Am I correct that the only definitive treatment 14 for pre-eclampsia is delivery? 15 A. Delivery. 16 Q. Is the same true that the only definitive 17 treatment for HELLP syndrome is delivery? 18 A. Yes. 19 Q. And that's true also with pregnancy-induced 20 hypertension -- 21 A. Correct. 22 Q. -- and all of its manifestations? 23 A. That is the final treatment and the best 24 treatment. 25 Q. Sure. PREMIER COURT REPORTING 330-494-4990 888-440-1418 28 1 A. And we're not talking about a 26- or a 28-week 2 where you may try to do things to buy time. 3 Q. Gotcha. Am I also correct in understanding that 4 after delivery it still takes considerable time 5 before the patient is stabilized and blood 6 pressure returns to normal and in HELLP syndrome 7 liver function returns to normal? Is that true? 8 A. Well, you had several components to that, so let's 9 address them. You need to manage the blood 10 pressure. You've got to get the pressure down and 11 keep it down while these other things are starting 12 to reverse. 13 The platelets may take two to three days 14 to come back. They usually continue to decrease 15 initially after you've delivered them and then 16 they will rebound. 17 As far as the hepatocellular, the liver 18 damage and the renal damage, it depends on the 19 degree of damage as to how long it will take. 20 They will reverse generally speaking. Some 21 patients may need dialysis for their kidney 22 problem. But once you have interrupted the 23 pregnancy and the placenta and whatever those 24 factors that are coming from the placenta, then 25 you can start the body's reparative processes. PREMIER COURT REPORTING 330-494-4990 888-440-1418 29 1 And it's like anything, you know, if you 2 see you've got to stop quickly, it takes awhile to 3 respond and it doesn't stop on a dime; you've got 4 to slow down a little bit. And sometimes in these 5 situations the problem may progress before it gets 6 better. But the key factor is to maintain the mag 7 sulfate to prevent seizures and to keep the blood 8 pressure down and under control. 9 Q. So in a patient like Mrs. Wright, is it true that 10 she would be at significantly increased risk of a 11 bleed, of subcapsular hemorrhage, even after 12 delivery? 13 A. Oh, sure. But again, remember that what we're 14 talking about here is we know that. And so how do 15 you try to prevent it? You try to prevent it by 16 strict management of the blood pressure. And just 17 for completeness sake, the one thing you don't 18 want to do is overcorrect. If someone has been 19 running a high pressure, the body adapts, 20 particularly in the brain. And so you don't want 21 to crash it down. You want to bring that pressure 22 down to a '90s diastolic, between 90 and 100, and 23 you want to keep it there for a while and bring it 24 down slowly. You don't want to crash it down, 25 because if you do, then the body can lose all of PREMIER COURT REPORTING 330-494-4990 888-440-1418 30 1 its mechanisms and then you can get into really 2 significant problems. 3 Q. What are the changes that occur in the body to 4 adapt to hypertension or is that outside of your 5 specialty? 6 A. I think you're getting outside of my specialty in 7 that aspect, except as an obstetrician our job is 8 to control the degree of the hypertension so that 9 the chance of significant prolonged or lifelong 10 complications doesn't occur. Now, when you get 11 into the cytokines and all that kind of stuff, I 12 would leave that to the internists or specialists 13 in hypertension. 14 Q. How do you as an obstetrician project which 15 patients are going to have HELLP syndrome? 16 A. You don't. You treat them all the same as if they 17 could develop it. In other words, you manage with 18 mag sulfate, with the antihypertensive, depending 19 on the level. The whole idea is management to 20 reduce the risk factors and if possible then 21 deliver the baby, but there's no way to -- If 22 they're mild pre-eclamptic, mild PIH, your chances 23 of developing into a full-blown difficult HELLP is 24 pretty low. The greater the severity, the greater 25 the risk factors involved. PREMIER COURT REPORTING 330-494-4990 888-440-1418 31 1 Q. Can you predict HELLP syndrome? 2 A. You can predict with a reasonable degree. If 3 you've got a very seriously sick patient with 4 severe pre-eclampsia, she's -- the only thing -- 5 Clarify. The only thing you can say is this 6 patient certainly is at risk to develop a HELLP 7 syndrome compared to the nonpre-eclamptic. 8 Q. When was this patient displaying signs or symptoms 9 that in your opinion placed her at risk for HELLP 10 syndrome? 11 A. Oh, when she came in, because she had such an 12 elevated blood pressure, four plus protein, which 13 already tells us we've got renal involvement here. 14 Q. You're talking about when she came into the 15 hospital for labor and delivery? 16 A. Yes. Her prenatal period was uncomplicated. 17 Q. I have probably made my last few questions very 18 unclear. How do you as an obstetrician predict 19 during the prenatal course that a patient is going 20 to have HELLP syndrome or can you? 21 A. Well, you really can't. You can have an idea of 22 predicting whether or not they may develop PIH in 23 watching their blood pressure, because if at 28 24 weeks their blood pressures don't drop, which it 25 should at that particular point of gestation due PREMIER COURT REPORTING 330-494-4990 888-440-1418 32 1 to hemodynamics -- if the pressures stay about the 2 same or are up a little bit, these people have a 3 much higher incidence of developing PIH at term 4 than a patient who follows the normal hemodynamic 5 profile during the prenatal period. But to be 6 able to sit there and say now, this patient is 7 going to develop HELLP syndrome, no, you can't do 8 that. 9 Q. Did Mrs. Wright display anything during her 10 prenatal course to indicate that she was likely to 11 have PIH, pre-eclampsia or HELLP syndrome? 12 A. Not really. Her pressures were fine. She gained 13 forty-one pounds during her pregnancy. Only at 14 the very end did she have some edema, but this was 15 ankle type edema, this was not generalized edema. 16 And certainly in a patient particularly that's had 17 a lot of children it's not surprising, even in the 18 first baby, to have the ankles swell up as you get 19 closer to term. So her prenatal period in my 20 opinion would be characterized as noncontributory 21 and uncomplicated. 22 Q. You authored a report several months ago, and of 23 course an important part of your role in this case 24 is to express opinions regarding deviation of 25 standard of care. PREMIER COURT REPORTING 330-494-4990 888-440-1418 33 1 A. Sure. 2 Q. And I want to ask you with regard to my clients. 3 And so first of all with regard to Dr. Liu, are 4 there any deviations of standard of care that you 5 have not set forth in your report? 6 A. Let me just look. I don't believe so, because I 7 have no other information since I wrote this 8 report. 9 Q. But do take time to review, because I may not ask 10 you about every single thing that you wrote, but I 11 want to make sure that I have a good comprehensive 12 view of your opinions. 13 A. From what I have written there and then looking at 14 that one sheet that I had to make sure I didn't 15 leave anything out -- 16 Q. That's Exhibit C? 17 A. Yes, I believe it is. Between these two, I 18 believe I've got them listed. 19 Q. Let me just ask a couple of follow-up questions 20 from that report. 21 A. Sure. 22 Q. You indicate in item one that he failed to come to 23 the hospital no later than 3 a.m.? 24 A. That's correct. 25 Q. Why 3 a.m.? PREMIER COURT REPORTING 330-494-4990 888-440-1418 34 1 A. At that time he knew the results of the liver 2 profile. He should have come in -- you know, I 3 tried to give when was the latest he should have 4 come. He should have come in when the patient 5 arrived and had the presenting symptoms, but 6 gaining the knowledge that she had a HELLP 7 syndrome mandated he come in at 3:00, 2:50. 8 Q. The second item you indicate as a deviation of 9 standard of care is failure to institute magnesium 10 sulfate. What is the latest that that could have 11 been administered and still comply with standard 12 of care in your opinion? 13 A. On admission. 14 Q. And you also mention antihypertensive therapy in a 15 timely manner. What is mandated for the 16 timeliness of antihypertensive therapy? 17 A. Systolic of greater than 160 and diastolic of 110 18 or greater. 19 Q. So based upon that answer, what you're telling me 20 is that antihypertensive therapy was mandated upon 21 the report of the initial presenting blood 22 pressure? 23 A. That's right or at the latest, in all fairness, at 24 the latest 2:00 when the diastolic was 111 or 113 25 and the systolic was still above 60. PREMIER COURT REPORTING 330-494-4990 888-440-1418 35 1 Again, as I say in all fairness, the 2 original diastolic was 100. The systolic was very 3 high. The initial bed rest, institution of mag 4 sulfate, even though that's not an 5 antihypertensive, but putting the patient in a 6 quiet room, institution of the mag and bed rest, 7 left lateral position, may have been sufficient to 8 bring the systolic down. But when you see an hour 9 later now it's still high and the diastolic is 10 over, that mandated at that point in time at the 11 latest that they should have started 12 antihypertensive therapy. 13 Q. Okay. I follow you. Now, magnesium sulfate, why 14 is that given? 15 A. Magnesium sulfate is for seizure prophylaxis. 16 Q. You've received a page. Do you need to answer 17 that? 18 A. Could we take just a couple minutes? 19 Q. Of course we can. 20 (A short break was taken.) 21 BY MR. PARKER: 22 Q. We were talking about magnesium sulfate, which I 23 understand is given to control seizures. Is there 24 any evidence that this patient suffered seizures? 25 A. Not during the time that she was on the labor and PREMIER COURT REPORTING 330-494-4990 888-440-1418 36 1 delivery floor. I couldn't tell you because of 2 the mental status later on whether or not there 3 was seizure activity, but from my reading I do not 4 believe that there was any evidence of a seizure 5 that occurred. 6 Q. Is it true that the primary purpose for 7 antihypertensive therapy in pregnancy-induced 8 hypertension patients is to prevent the risk of a 9 bleed into the brain? 10 A. That's one area, correct. In fact, the risk of 11 bleeds, the brain is obviously the first one 12 you're concerned about. 13 Q. Do you have an opinion as to whether there was a 14 bleed into the brain in this case? 15 A. Based on the original -- The only CAT scan that I 16 saw, and there may have been others, but the 17 original one I believe showed a diffuse edema. 18 And that is not consistent with my knowledge level 19 that there was an acute bleed into the brain. 20 Q. Have you reviewed any CAT scan films? 21 A. No, sir. 22 Q. So when you talk about a review of a CAT scan, you 23 mean the report in the records? 24 A. That's correct. 25 Q. Fair enough. I'm looking at the other findings in PREMIER COURT REPORTING 330-494-4990 888-440-1418 37 1 your report with regard to Dr. Liu to see if I 2 have any other follow-up questions there. Okay. 3 Another client that I have is the certified 4 nurse-midwife. And if you would take a look at 5 your report and your written notes with regard to 6 her. 7 A. Sure. 8 Q. I want to see whether you have any additional 9 opinions that you have not expressed in your 10 report or in that written notation. 11 A. Here we go. I'm looking at page 6 of my report. 12 Q. Between the two pages that we have referred to, 13 namely, starting on page 6 of my written report 14 and ending with the first paragraph on page 7, and 15 then the deviations that are also reiterated in a 16 slight degree of expansion on the page -- And you 17 have it marked. I'm not sure which one says 18 deviations Nuza. I don't remember which one is -- 19 Q. Exhibit J. 20 A. Exhibit J. Okay. Between those two, I think 21 that's complete, sir. 22 Q. Okay. Give me a moment, please. I do not see 23 Dr. Gyves addressed. Do you have an opinion as to 24 any deviations from the standard of care by 25 Dr. Gyves? PREMIER COURT REPORTING 330-494-4990 888-440-1418 38 1 A. Yes, I have an opinion. 2 Q. And what is that opinion? 3 A. In my opinion Dr. Gyves did not deviate from 4 accepted standards of care in his management of 5 this patient. 6 Q. Let me ask you this. If Dr. Liu had seen this 7 patient at 3 a.m., do you have an opinion as to 8 what would have occurred differently? 9 MR. FRASURE: I'm sorry. If he would 10 have what? 11 Q. Come into the hospital at 3 a.m. Tell me your 12 opinion as to what would have occurred differently 13 from that point on. 14 A. Well, that's an open question based on the 15 predicate that he would properly evaluate and 16 properly manage the patient. If he had come in 17 and 3:00 and recognized the symptomatology that 18 the patient had and particularly was there giving 19 hands-on, trying to maintain the pressure, then 20 when the patient complained of the shoulder pain, 21 if the regulation of the blood pressure had not 22 been successful and she complained of the shoulder 23 pain, he would have immediately sectioned the 24 patient recognizing that she is not a candidate. 25 And that was at approximately 3:45. So by 4:00 PREMIER COURT REPORTING 330-494-4990 888-440-1418 39 1 the patient would have been delivered. 2 Q. I'm sorry, I don't mean to cut you off, but I am 3 interested in why does the complaint of shoulder 4 pain take the patient out of the possibility of a 5 vaginal delivery? 6 A. Because now you have evidence of subcapsular 7 hemorrhage, you have evidence of swelling of the 8 Glisson's capsule. That is a very ominous sign 9 and it means immediate delivery. 10 Q. So evidence of subcapsular hemorrhage in and of 11 itself demands -- 12 A. Immediate delivery. 13 Q. -- immediate procedure to C-section? Am I 14 understanding your opinion correctly? 15 A. Well, if you expect the patient to deliver in a 16 very short period of time, within thirty minutes. 17 And the reason I say that is if they had 18 started -- for example, if this was a multip of 19 3 centimeters and they started Pitocin when she 20 first got there and she's now 8 centimeters, you 21 would anticipate you're going to have a rapid 22 delivery here. But in a patient that has a 23 noninducible cervix, you don't try Cervidil when 24 you get to that point. She's already had the 25 headache. She's got the elevated liver enzymes, PREMIER COURT REPORTING 330-494-4990 888-440-1418 40 1 she's got a blood pressure that's totally out of 2 control, and now she's got the shoulder pain. 3 That means you have got to move for immediate 4 delivery and by the most expeditious manner. 5 Since she's not a candidate for vaginal, then you 6 do a section. 7 Q. So if a C-section is performed as quickly as is 8 reasonable after 3:50, is it possible there could 9 still be subcapsular hemorrhage? 10 A. Sure. 11 Q. How likely is that? 12 A. Oh, it's hard to say. Again, you have to use the 13 idea did he actively begin to try to manage her 14 blood pressure. If he left her blood pressure up 15 like that and didn't use antihypertensives, then 16 you've increased the risk of the actual rupture, 17 not just the cellular damage and the bleeding but 18 the actual bleeding into and then rupture of the 19 capsule. That's why I said, when you said if he 20 comes in how would it change. Well, it changes if 21 he knows what he's doing. But if he's not going 22 to do anything based on his testimony, then it's 23 not going to change a thing. 24 Q. Once a subcapsular hematoma forms, is the 25 administration of antihypertensives going to make PREMIER COURT REPORTING 330-494-4990 888-440-1418 41 1 that hematoma go away or decrease in size? 2 A. It may not go away or decrease in size, but you've 3 reduced the pressure head. You may reduce the 4 degree of expansion. You may actually prevent the 5 actual rupture because you've reduced that 6 pressure head and you've got a tamponade effect 7 there. 8 Q. As you answered that question, you told me about a 9 number of things that may happen. Are those 10 things more likely than not going to happen? 11 A. I understand what you're asking. And at that 12 particular point in time, had the blood pressure 13 been properly managed, then in all probability she 14 wouldn't have ruptured her liver. 15 Q. And why do you say that? 16 A. Because you would have reduced the pressure head. 17 You would have reduced the likelihood that you're 18 going to have a propagation of the bleeding and 19 the tamponade would not have worked. If you don't 20 reduce the pressure head and you're producing more 21 and more blood into that without cutting down on 22 the force, then you have a greater propensity that 23 that capsule is going to rupture. 24 Q. Are there any studies or data that you're aware of 25 that support this concept that once there is a PREMIER COURT REPORTING 330-494-4990 888-440-1418 42 1 subcapsular hematoma that has formed that the 2 reduction of the patient's blood pressure is going 3 to actually have a demonstrable effect in terms of 4 reducing the likelihood of rupture? 5 A. The only way I can answer that -- and I'm not 6 trying to be evasive, but this is discovery so 7 this is what I'm going to tell you. First of all, 8 there have not been enough capsular ruptures of 9 the liver to be able to do any kind of study. 10 Secondly, you would never set up a study saying 11 well, let's just try this on this patient and not 12 try it on this patient and see who ruptures and 13 dies. 14 But the treatment of severe PIH or severe 15 pre-eclampsia is control of pressure and mag 16 sulfate. Why? To reduce the incidence of 17 bleeding problems or ruptured vascular problems 18 associated with the marked hypertension. That's a 19 caveat of treatment. And, two, to prevent 20 seizures. So the treatment answers your question. 21 Do you see what I mean? 22 Is there a study that can give you a 23 conclusive answer to that? I don't believe there 24 is. It would all be anecdotal anyway because it's 25 so rare. There are not very many that have had PREMIER COURT REPORTING 330-494-4990 888-440-1418 43 1 actual hands-on experience with a ruptured liver 2 associated with pre-eclampsia. But the treatment 3 that's espoused throughout this discovery depo as 4 well as if you read the treatises, go to 5 conferences, read the textbooks, read the 6 summarizations, the treatment is designed to 7 prevent the severe complications. HELLP syndrome 8 in and among itself is not fatal, but untreated 9 with the problems that assist in the development 10 of the HELLP syndrome may be the fatal episode, 11 the seizure with the brain hemorrhages, the 12 ruptured liver. Do you see what I mean? 13 Q. Yes. 14 A. So that's the only way I can really answer that 15 and try to give you any kind of logical opinion. 16 There's no good study. But the treatment 17 modalities are designed to prevent exactly the 18 complications that we're talking about, and 19 failure to do those treatment modalities in all 20 probability increases the risk that they will 21 occur. I can't give you a line by line, if we had 22 done it at this, is there a 10 percent, 20, 50, 23 60. I can't do that. There's not enough studies. 24 Q. Do you know what the incidence of liver hemorrhage 25 and rupture associated with delivery is? PREMIER COURT REPORTING 330-494-4990 888-440-1418 44 1 A. Depending on who you read -- The figure that most 2 people throw around is about one in 40,000. Some 3 studies make it even more rare than that. If you 4 have several sources say that they would estimate 5 it to be about one in 40,000, there's no reason to 6 dispute that. 7 Q. And what is the mortality associated with liver 8 rupture in delivery? 9 A. Mortalities have been decreasing. In the older 10 literature when we first started into this HELLP 11 syndrome and ruptured livers and that, mortality 12 could approach 80 percent. Since there has been 13 greater knowledge and awareness of these 14 particular problems and diagnostic studies that 15 could be done such as ultrasounds or CAT scans -- 16 ultrasound is better in OB -- and referral to 17 tertiary centers for management of these problems, 18 the mortality rate has decreased markedly. The 19 latest figures coming out I couldn't give you 20 exact, but I would say within a reasonable degree 21 it would be around 20 percent. 22 Q. And where have you seen those figures? 23 A. I'm trying to remember the last time I went to the 24 meetings what the figures were. There was a 25 conference I went to that Reed and Creasy put on. PREMIER COURT REPORTING 330-494-4990 888-440-1418 45 1 Those are the authors of one of the textbooks. 2 And I believe at that time the figure was down 3 around 20 percent. That was last year. 4 Q. And is that a mortality rate for liver rupture in 5 general or liver rupture in delivery? 6 A. I couldn't tell you that because of all the 7 reasons where livers may rupture. I can only 8 address the obstetrical. And the conference I 9 went to was in high-risk obstetrics, so I would 10 think that it would have to be limited to that, 11 but I couldn't say for sure. 12 Q. Have you encountered liver rupture in delivery in 13 your practice? 14 A. Personally in my practice, no. Being involved 15 with it, yes, two of them. 16 Q. And what do you mean by being involved with it? I 17 guess you'll have to describe your involvement. 18 A. Well, very peripherally. One as the attending for 19 the residents. It was a house case that ruptured. 20 I wasn't on but I was involved during different 21 days as part of the teaching program. And the 22 other was a patient of a gentleman, Dr. Richard 23 Bennett. He and I covered for each other for 24 almost twenty-five years. And one of his patients 25 ruptured and I became involved on a peripheral PREMIER COURT REPORTING 330-494-4990 888-440-1418 46 1 basis. 2 Q. Did you say that was a patient of Dr. Bennett? 3 A. Richard Bennett, yes. 4 Q. And what was the outcome for that patient? 5 A. She died. 6 Q. What about the outcome for the patient on the 7 residency program? 8 A. That patient survived. 9 Q. And when was that? 10 A. Well, the residency patient I believe -- I believe 11 it was a residency patient because I was involved 12 with it, unless it was a private turned over to 13 house. And that was probably eight or nine years 14 ago. Dr. Bennett's was at least twenty years ago. 15 Q. What is it physiologically with HELLP syndrome 16 that causes liver abnormalities and ultimately 17 causes the liver to bleed? 18 A. Well, it's the -- again this is theory but it's 19 pretty generally accepted. Nobody knows the exact 20 cause of toxemia, but we know that it's vasospasm 21 of small vessels. And the vasospasm of the small 22 vessels causes interruption of normal platelets. 23 The platelets aggregate and clot and block the 24 vessels and can also then -- that's part of 25 HELLP -- reduce platelets, low platelets. And PREMIER COURT REPORTING 330-494-4990 888-440-1418 47 1 under the circumstances then you have decreased 2 adequate perfusion of the tissues particularly of 3 the kidney and of the liver. When you have 4 decreased perfusion, then you get cellular damage 5 either in the glomerulus as expressed by hematuria 6 or proteinuria or in the liver as expressed by 7 elevated enzymes. And that's the etiology of it. 8 It's a vasospastic disease. So what you're trying 9 to do is reduce pressure heads by controlling the 10 pressure, but we don't have the magic drug to 11 treat toxemia. 12 Q. At the risk of going back to one of the first 13 topics that we discussed today, is it the same 14 disease that manifests itself in HELLP syndrome by 15 causing the ischemic liver damage, is that same 16 disease as manifests itself in pre-eclampsia in 17 causing the kidney damage or are they different or 18 do we know? 19 A. Well, first of all, when you have severe 20 pre-eclampsia and you develop the complex of the 21 HELLP syndrome, they're associated. But is it 22 absolute? Within a reasonable degree of 23 probability, one is associated with the other. 24 But is it absolute? No, because remember, as I 25 said, you can have a normotensive HELLP syndrome PREMIER COURT REPORTING 330-494-4990 888-440-1418 48 1 which is not pregnancy-induced hypertension. 2 That's very rare, extremely rare. So the thing 3 that you look for -- and I hate to beat a dead 4 horse, but the thing you look for is control the 5 pressure, protect the brain and deliver the baby. 6 Q. If the baby were delivered earlier, do you believe 7 that there would be a different outcome as far as 8 the bleeding complication in this case? 9 A. Yes. 10 Q. And why do you believe that? 11 A. Well, number one, you've removed the placenta, so 12 whatever the generating factor is, you're starting 13 to reverse that process. And, number two, I'm 14 making it with the caveat that in the process of 15 making the arrangements for the delivery you're 16 going to control the blood pressure. And the 17 third caveat is the fact that if the delivery is 18 going to occur, that means the doctor has to be 19 there. And he wasn't. 20 Q. How much earlier did delivery have to be to have a 21 different outcome? 22 A. I think your last point of opportunity was a 23 quarter of four. 24 Q. What happened at a quarter of four that made the 25 patient more likely not going to have the bleeding PREMIER COURT REPORTING 330-494-4990 888-440-1418 49 1 problem before that time, more likely going to 2 have the bleeding problem after that time? 3 A. I'm sorry, quarter of five when she had the -- 4 It's getting late. At the time of the shoulder 5 pain, 3:50 or 4:50, whenever that was. 6 Q. 3:50 I believe. 7 A. 3:50. I was right then. 8 Q. I'm not under oath, but I think it was 3:50. 9 A. I believe you're right. But anyway -- 10 MR. FRASURE: Can you start again? I 11 lost you a little bit. 12 MR. PARKER: 3:50 I think is the time of 13 the shoulder pain. 14 MR. FRASURE: When did you say the last 15 opportunity was? 16 A. You asked when were the last opportunities. 17 Definitely when the shoulder pain occurred. That 18 should have effected immediate delivery. We've 19 already discussed that. And then as the final 20 last window of opportunity -- although I would 21 prefer and I think the standards and requirements 22 would mean that when the shoulder hit you had to 23 get the baby out. But the final would have been 24 when the bradycardia occurred. And had he been 25 there, he could have had the baby out in fifteen PREMIER COURT REPORTING 330-494-4990 888-440-1418 50 1 minutes, so by 4:30. 2 Q. If you're giving me two different opportunities, 3 then I'm not asking my question well. I'm trying 4 to find out at what time the patient goes from 5 probably not having a severe bleeding complication 6 to probably having a severe bleeding complication. 7 MR. HIRSHMAN: Do you want to know when 8 the window of opportunity closed for her to 9 not have neurologic deficits? Is that what 10 you're asking? 11 MR. PARKER: I want to find out when 12 the window of opportunity closed for her not 13 to have the severe bleeding complication 14 that led ultimately to the neurological 15 deficits. 16 MR. FRASURE: Are you assuming the 17 treatment is the same as occurred up until 18 that point or are you assuming the treatment 19 is as he is saying should have happened? 20 MR. PARKER: Well, actually I want to 21 see if he needs to put that caveat in. 22 THE WITNESS: I have to. 23 Q. That's fine. 24 A. I have to. Okay. We'll do it two ways, with or 25 without the treatment. PREMIER COURT REPORTING 330-494-4990 888-440-1418 51 1 Q. That's fine. 2 A. First, when the liver enzymes came back elevated 3 at 2:50 and the pressure is high and everything is 4 untreated, the patient needed to be delivered 5 immediately. And that would have broken the cycle 6 and hopefully within a reasonable degree of 7 probability prevented the liver rupture. 8 MR. HIRSHMAN: Those came back at -- 9 THE WITNESS: 2:50. 10 MR. HIRSHMAN: I'm looking at the orders 11 here. 12 A. The orders were written an hour earlier. It takes 13 about an hour to get the results though. Give or 14 take a minute, it was about 2:50. When Dr. Liu 15 was called by the nurse-midwife at 2:50 16 demonstrating the sky-high pressure, the fact that 17 we now have low platelets, four plus protein, 18 elevated liver enzymes, and an inducible cervix, 19 "Doctor, the patient is on her way to the 20 operating room. We'll be ready for you as soon as 21 you get here." That's it. 22 Q. What changed in the patient's condition so that if 23 delivery was accomplished at 3:00 we'd have a 24 different outcome? 25 MR. HIRSHMAN: I'm not sure that's what PREMIER COURT REPORTING 330-494-4990 888-440-1418 52 1 he said. 2 A. The anesthesiologist, if you're going to deliver 3 the patient by section, would be there and have 4 the patient's pressure under control. So, 5 therefore, you've interrupted the hypertension 6 that Dr. Liu refused to acknowledge as even an 7 emergency, you have interrupted the pregnancy by 8 removing the placenta, and you have a qualified 9 physician who recognizes that we've got to get 10 this blood pressure down with an anesthesiologist 11 who is going to control that blood pressure 12 because he's going to have a woman having a 13 delivery and then would definitely be involved in 14 the control of the blood pressure post-op. 15 So under those circumstances, 3:00, 2:50, 16 give him twenty minutes to get there. He said he 17 could make it in twenty to twenty-five. We know 18 now he can't, but he said he could make it in 19 twenty to twenty-five. So give him the benefit of 20 the doubt, 3:15 max. He was informed at 2:50. So 21 3:20 to 3:25. That's the one you want. 22 Now, if you had treatment and you've got 23 the pressure head coming down and the patient is 24 stabilized but now develops right shoulder pain, 25 that's it. Regardless of how well you may think PREMIER COURT REPORTING 330-494-4990 888-440-1418 53 1 you have her under control, you must get the baby 2 delivered. At that point in time I'm not so 3 sure -- well, at that point in time we still -- 4 when she developed the shoulder pain she's got 5 definite swelling of Glisson's capsule. We don't 6 have any evidence of rupture. Her pulse is still 7 in the 60s. So at that point in time you deliver 8 the baby, again you've reversed the process, and 9 again you've got the pressure under control. The 10 placenta is out, the baby is out, the patient is 11 in an intensive care environment. So I don't 12 think she'd have ruptured. 13 Rupture of the liver is extremely rare, 14 and I would suspect that -- Well, I'll just leave 15 it at that. It's extremely rare. 16 Q. Are you suspecting there was an additional 17 occurrence or factor that led to the rupture? 18 A. You bet. 19 Q. And what was that? 20 A. The doctor and the nurse-midwife that allowed this 21 to go on without proper treatment. That's your 22 factor. I didn't want to say that. But since you 23 brought it up, there it is. 24 Q. I want to know where you're coming from. 25 A. That was the deciding factor as to why the woman PREMIER COURT REPORTING 330-494-4990 888-440-1418 54 1 ruptured her liver. 2 Q. Can you tell me how long it takes after delivery 3 in the presence of HELLP syndrome for platelets to 4 return to normal? 5 A. I thought we mentioned that. It usually takes two 6 to three days. 7 Q. Is it the same time frame after delivery in a 8 HELLP syndrome patient for the blood pressure to 9 return to normal? 10 A. Well, that's variable. There's no way to say. 11 Some of these patients actually have to go on 12 antihypertensives for a month or two. So they 13 continue to need to have their pressure 14 controlled. 15 Q. Are there particular antihypertensives that you 16 feel were appropriate for this patient? 17 A. With this patient you'd either use hydralazine or 18 labetalol. Those are the two standard drugs that 19 you can give. And again the reason I say that is 20 these are well researched, tried and true 21 intravenous drugs to use to bring a pressure down 22 that you can titrate, because you don't want to 23 crash the pressure. 24 Q. Do you have an opinion as to what blood pressure 25 reduction was achievable with this patient on PREMIER COURT REPORTING 330-494-4990 888-440-1418 55 1 those medications? 2 A. Oh, sure. There's no reason to suspect that this 3 patient could not have been brought down within -- 4 to the 140 to 150, to the 90 to 100 initially, and 5 then you would maintain around 90 for the first 6 day or two afterwards unless she was spontaneously 7 coming down. 8 Q. And how long would it take for administration of 9 these medications to reasonably bring this patient 10 down to that level? 11 A. Ten to fifteen minutes. 12 Q. Did this patient have any risk factors for PIH or 13 pre-eclampsia or eclampsia or HELLP syndrome 14 before her presentation to the hospital on the day 15 of delivery? 16 A. Well, there's little controversy with that. Yes. 17 She was a super grand multip. She had fourteen or 18 fifteen pregnancies. But she was also older. And 19 an older patient, the multips or the prima 20 gravidas, as you get older you have a chance to 21 develop other medical problems that can be 22 associated with pregnancy, too. So grand 23 multiparity may be one of them. She was not 24 morbidly obese or anything along that line. 25 Overall she would not be considered at a high risk PREMIER COURT REPORTING 330-494-4990 888-440-1418 56 1 for developing it. 2 Q. I have read, and I want to see if you agree, that 3 hypertensive disease in pregnancy is responsible 4 for about 15 percent of maternal deaths in the 5 United States. Do you know if that's true or 6 rings true? 7 A. Well, it's a significant factor in the etiology of 8 maternal death, but it depends on how they break 9 it out. You know, this patient died as a 10 consequence of hypertension, but she also 11 hemorrhaged, she also had these other problems. 12 Which one would they code it? Do you see what I 13 mean? 14 Q. I hear you. 15 A. Hypertension is a significant contributing factor 16 to maternal mortality. It's rare but it's 17 significant. 10 percent, 15 percent, 20, 25 18 percent. It depends on how the research codes 19 them out. 20 Q. Can patients die of PIH and its related diseases 21 and syndromes in the absence of medical 22 negligence? 23 A. Anything is possible. I'm making the assumption, 24 when you say in the absence of medical negligence, 25 that the patient was properly cared for at the PREMIER COURT REPORTING 330-494-4990 888-440-1418 57 1 appropriate times and the appropriate medications 2 and yet still died. It's possible. 3 Q. Dr. Gatewood, at the beginning of this deposition 4 you told me that you had occasion to be deposed 5 previously. About how many times has your 6 deposition been taken in connection with medical 7 negligence cases? 8 A. We came up with -- because this question is asked. 9 I've been doing this since 1977, and I think a 10 reasonable estimate would be about 200 times. 11 Q. Can you tell me roughly what percentage of the 12 times you testify for claimants versus the 13 percentage of times that you testify for health 14 care providers? 15 A. In other words, plaintiff versus defense? 16 Q. Sure. 17 A. When I started, for the first several years it was 18 100 percent defense. There was an evolution in 19 the last, oh, maybe fifteen years. It's now 20 probably 90 percent plaintiff, 10 percent defense, 21 review and/or deposition. Deposition actually or 22 trial would probably be more 95 percent plaintiff. 23 But overall with everything combined, probably 24 90/10. 25 Q. Have you had occasion to testify for Mr. Hirshman PREMIER COURT REPORTING 330-494-4990 888-440-1418 58 1 before? 2 A. No, sir. Wait a minute. I have to take that 3 back. I don't know if I ever did when he was with 4 PIE. 5 MR. HIRSHMAN: No, I just had a case 6 against you once. That's all. 7 Q. When were you first contacted with regard to this 8 case? 9 A. December of 1998. 10 Q. What do you charge for review, deposition and 11 testimony? 12 A. I charge $1,500 for review. I charge $1,500 for 13 deposition for a three-hour minimum, $500 an hour 14 above that. I charge $2,500 a day for trial plus 15 travel if I have to travel. 16 MR. PARKER: I'll review my notes. I 17 may have a few more questions, but I think 18 I'm largely done. Mr. Frasure may have 19 questions for you. 20 - - - - - - - 21 CROSS-EXAMINATION 22 BY MR. FRASURE 23 Q. Dr. Gatewood, my name is Mark Frasure. I 24 represent Nurse Burton. She's not the midwife. 25 She's an R.N. in the labor delivery. PREMIER COURT REPORTING 330-494-4990 888-440-1418 59 1 A. Correct. 2 Q. And also I represent the hospital who has been 3 sued. 4 Just to follow up on a few questions that 5 Mr. Parker has asked you, you said you've 6 testified roughly about two hundred times in 7 medical-legal cases. About how many per year are 8 you getting to review now, not that necessarily go 9 to deposition but that come into your office or 10 your home with records that you review and give an 11 opinion on? 12 A. At the present time I would say about thirty to 13 forty. 14 Q. Per year? 15 A. Yes, sir, of cases that I review, that's correct. 16 Q. And that's been true for the last several years? 17 A. I think that -- the reason I say thirty to forty, 18 it's starting to reduce now. I used to say, you 19 know, I would do three or four a month until 20 someone pointed out that that was almost one a 21 week, and I realized that I wasn't doing that. I 22 think the busiest year I might have ever had I 23 could have done forty, but as a general rule it's 24 around thirty, thirty-five. 25 Q. Roughly -- I don't want to know what your income PREMIER COURT REPORTING 330-494-4990 888-440-1418 60 1 is, but can you say roughly percentage-wise of 2 your total professional income? 3 A. Approximately 25 percent. 4 Q. Comes from medical-legal matters? 5 A. That's correct, 25 percent of gross billings is 6 from medical bill. 7 Q. Have you reviewed a case for anybody else in 8 Mr. Hirshman's firm? 9 A. No, sir, not that I'm aware of. 10 Q. You don't know any of the doctors here, do you? 11 MR. HIRSHMAN: Do you want to tell him 12 who's in my firm? I don't think he 13 necessarily knows that. 14 MR. FRASURE: Just tell him who the 15 other people are. 16 MR. HIRSHMAN: Ellen Hirshman and Bob 17 Linton. 18 THE WITNESS: Bob Linton? 19 MR. HIRSHMAN: Jr. 20 A. No, I don't believe so, sir. I'm sorry. I missed 21 your last question. 22 Q. Do you know any of the doctors involved here? 23 A. No, I don't. I've never met them. I've heard of 24 Dr. Gyves. But no, I've never met them. 25 Q. Have you had any contact with St. Luke's Medical PREMIER COURT REPORTING 330-494-4990 888-440-1418 61 1 Center? 2 A. No, sir, I have not. 3 Q. Dr. Liu testified in his deposition that the 4 reason he did not give antihypertensives is that 5 he felt that that would put the baby at too much 6 risk. I take it you disagree with that. 7 A. Absolutely. 8 Q. And why? 9 A. Because if it's given properly, what you're doing 10 is increasing the blood flow to the placenta and 11 decreasing any potential hypoxia to the baby. 12 However, if you don't know how to give it and you 13 give too much of it and you crash the pressure, 14 then yes, that's detrimental. But if you do it -- 15 Q. What period of time do you titrate it, the 16 antihypertensive medications in this kind of case? 17 A. You give your medication, you wait ten to fifteen 18 minutes to see the result, you give the next dose, 19 usually at ten- to fifteen-minute intervals. 20 Q. And you believe it would have been successful here 21 within twenty minutes or so? 22 A. I think you would have seen a response within 23 twenty minutes, sure. 24 Q. At approximately what level, Dr. Gatewood? 25 A. We should have a diastolic below 105 within ten to PREMIER COURT REPORTING 330-494-4990 888-440-1418 62 1 twenty minutes and down to the level of about 100 2 no later than a half an hour. 3 Q. And what would the systolic need to get down to to 4 be careful? 5 A. Well, the systolic is not that much of a critical 6 factor, but your systolic would drop in a 7 corresponding manner. I would imagine if you can 8 get the diastolic down to the level of 100 within 9 thirty minutes from the 111 or 112 that it was, 10 your diastolic should be down to 150 to 160 11 because you are getting a decrease rather than an 12 increase. 13 MR. HIRSHMAN: You meant the systolic 14 down to 150 to 160? 15 THE WITNESS: Yes. What did I say? 16 MR. HIRSHMAN: You said diastolic. 17 A. I thought I said diastolic 90 to 100, around the 18 100 range, and the systolic down to 150 to 160. 19 Q. One of your criticisms against Nurse Burton is 20 that she didn't take the blood pressure often 21 enough and/or didn't document it enough? 22 A. That's correct. 23 Q. Can we agree that the blood pressures that were 24 documented, it's rather clear to the doctor, 25 assuming that he's being told, that the blood PREMIER COURT REPORTING 330-494-4990 888-440-1418 63 1 pressure is quite high here? It's not as if the 2 blood pressure went down and came back up; 3 correct? 4 A. That's correct. 5 Q. It remained high? 6 A. Yes. 7 Q. It got higher after the initial levels, didn't it? 8 A. Sure. 9 Q. And that increase was documented, right? 10 A. That's correct. 11 Q. Mr. Parker asked you about your experience with I 12 think it was ruptured livers during pregnancy? 13 A. That's correct. 14 Q. What has been the extent of your experience, 15 Dr. Gatewood, with a patient that has HELLP 16 syndrome with or without a ruptured liver during 17 pregnancy? 18 A. I've seen several patients that have had HELLP 19 syndrome. I've had two patients in the last year 20 here in Oberlin, and that's maybe two percent. 21 That's based on about a hundred deliveries that I 22 did. We saw it much more frequently obviously at 23 City Hospital in a large teaching program. But in 24 my own private patients, you'll see a HELLP 25 syndrome maybe two to three percent of the time. PREMIER COURT REPORTING 330-494-4990 888-440-1418 64 1 Q. A couple times a year? 2 A. A couple or three times a year, yes. 3 Q. Generally were those instances in which HELLP was 4 discovered early in the pregnancy or midway 5 through the pregnancy? 6 A. I've never seen a HELLP syndrome except in a 7 patient who was admitted to the hospital. 8 Q. In other words, near term? 9 A. Well, not necessarily near term but associated 10 with hypertension and then in the serial testing 11 starts to develop elevation of the liver enzymes, 12 the low platelets and the HELLP syndrome. 13 Obviously we wouldn't be testing on an outpatient 14 basis for HELLP syndrome. The patient has to be 15 admitted. 16 Q. Oh, I understand. I'm not questioning whether 17 outpatient or inpatient, just at what point in the 18 pregnancy have your HELLP patients tended to be. 19 Early, mid, late? 20 A. Oh, I see. I'm sorry. I misinterpreted your 21 question. It can be anywhere. I couldn't say 22 that they've all been late or -- Okay. I've 23 never had one to my knowledge under twenty-eight 24 weeks. 25 Q. All things being equal, can you say whether it's PREMIER COURT REPORTING 330-494-4990 888-440-1418 65 1 better to have it late in the pregnancy like this 2 was or midway or -- 3 A. The further along in the pregnancy, the better the 4 outcome is going to be because you're able to 5 treat the disease, and that's deliver the baby. 6 Q. Excluding for the moment the blood pressure 7 documentation that we've already talked about, 8 what was it about this patient and Dr. Liu's 9 response or lack of response that first required 10 the nurse within the standard of care to do 11 something to insist that he come in -- and this is 12 not Nurse Nuza, I don't represent her, but Nurse 13 Burton to insist that he come in or to go up the 14 chain of command to get someone there? What was 15 the first thing about the patient and/or the 16 doctor's response that triggered that? 17 A. 2:50. 18 Q. And 2:50 is the return of the blood levels? 19 A. Right. At that point you have now confirmed that, 20 number one, bed rest, turning out the lights, 21 things like that are not going to help reduce the 22 pressure. Number two, the mag sulfate has been 23 ordered, and the hospital policies are clear that 24 they can not be ordered unless the physician has 25 evaluated the patient. And so at the point that PREMIER COURT REPORTING 330-494-4990 888-440-1418 66 1 you're obviously dealing with a HELLP syndrome, 2 the nurse-midwife is not qualified handle this. 3 The nurses, I believe almost -- just about all of 4 them stated that they personally had not been 5 involved with treating HELLP syndrome. And the 6 main thing is the doctor wants to start the mag. 7 He's not controlling the pressure. We have a very 8 sick patient. The nurse even in her deposition 9 stated that she thought the doctor would come in 10 at that point in time, 2:50. 11 Q. At 2:50. Okay. You mentioned about the nurse 12 saying she had not had any experience with HELLP. 13 What has been your general experience, Doctor, 14 with nurses in the hospital in labor and delivery 15 with the amount of experience with HELLP syndrome? 16 A. Well, it depends obviously on the hospital. If 17 you have a Level III hospital, it's quite common 18 and the nurses are quite familiar with it. If you 19 have a Level II -- There were perinatologists on 20 staff at this hospital. So HELLP syndrome is not 21 something that one would consider a very isolated 22 event, particularly as was pointed out by the 23 different people in the depositions of the patient 24 population of St. Luke's, which is an inner city 25 type hospital with a higher incidence of PREMIER COURT REPORTING 330-494-4990 888-440-1418 67 1 complications. The smaller you get -- To be 2 honest with you, I think the HELLP syndromes I 3 managed here were the first time the nurses have 4 been involved with it because they had always been 5 transferred. So increasing level of 6 sophistication, increasing frequency of management 7 of HELLP syndrome. Decreasing, less exposure of 8 the nurses to it. And when you're only doing a 9 few deliveries like St. Luke's was at that point 10 in time, the nurses may not have had the training 11 or the exposure to it. 12 Q. Going back to the 2:50 time frame, what did the 13 standard of care require Nurse Burton to do? 14 A. Simply inform the nurse-midwife that she cannot 15 start the mag sulfate without the physician being 16 present, and obviously their concern over the 17 pressure and the patient, that this was a very 18 sick patient. But the absolute rule is that the 19 physician must physically evaluate the patient 20 before you can start Pitocin -- I'm sorry, mag 21 sulfate. And so that would have been mandatory 22 and that's why I waited until 2:50. If the doctor 23 had ordered it at 1:50 when she came in, then 24 that's the time that they should have called him. 25 Q. Do you ever order mag sulfate over the phone for a PREMIER COURT REPORTING 330-494-4990 888-440-1418 68 1 patient in labor? 2 A. Not without having seen the patient at least one 3 time or another. Now, if I have a patient that 4 comes in -- I'm only five minutes away from here. 5 If I have a patient that comes in with high blood 6 pressure, I will tell them get the mag sulfate, 7 I'm on my way in and I'll check her out. But the 8 nurses here can't start mag sulfate unless I've 9 evaluated the patient. 10 Q. Is there a risk in starting mag sulfate if it's 11 not needed? 12 A. The risk is very low. Improperly administered -- 13 You have to check for reflexes and that. If you 14 give too much, the patient could stop breathing. 15 Q. It was not improperly administered here except in 16 your opinion it should have been administered 17 sooner; right? 18 A. That's correct. 19 Q. It was not contraindicated to administer it right 20 away, was it? 21 A. No, sir. 22 Q. Isn't the purpose behind having a doctor evaluate 23 a patient before ordering mag sulfate to be sure 24 that the patient really needs it? 25 A. Well, it's to evaluate the patient's physical PREMIER COURT REPORTING 330-494-4990 888-440-1418 69 1 status and in that aspect as a corollary, yes, to 2 make sure they need it. You've got to have a 3 physician come in. 4 Q. And you take evaluation to mean that it has to be 5 hands-on rather than being told what's going on by 6 people at the scene? 7 A. Well, unless it's another physician. If this were 8 at a time when this hospital had house physicians, 9 that would be perfectly acceptable. But the rules 10 are very clear. You have to have a physician 11 evaluate the patient. 12 Q. I think Dr. Liu testified that he believed there 13 was HELLP going on as of about 2:50. Do you agree 14 that that's when it became clear? 15 A. It was obvious at 2:50. 16 Q. With the arrival of the labs? 17 A. Correct. 18 Q. Am I clear in understanding that the patient was 19 already bleeding some within the liver itself by 20 the time she arrived? 21 A. Oh, she would have to be, because you have the 22 elevated enzymes. 23 Q. Right. And then at some point -- How did you 24 describe it? I think you described that the liver 25 capsule was stretched around 3:45; that's when the PREMIER COURT REPORTING 330-494-4990 888-440-1418 70 1 shoulder pain was diagnosed or was observed? 2 A. There was the beginning of the irritation of the 3 liver capsule, yes. 4 Q. And by the liver capsule, that's the liver itself? 5 A. Well, no. It's a peritoneal covering. It's 6 called Glisson's capsule. 7 Q. The actual hematoma, does that start forming at 8 that point? I'm a little unclear on that. 9 A. Well, the covering or Glisson's capsule has 10 stretch fibers in it. And the stretch fibers -- 11 as the hematoma starts to form, you will stretch 12 the capsule. And as you reach a certain critical 13 point, it triggers a sensation that's called pain. 14 I can't tell you how many cc's it takes to cause 15 the pain. The other thing is before you start to 16 bleed -- You don't have to have a hematoma to get 17 right upper quadrant pain. Maybe we're confused 18 on that issue. You get swelling of the liver with 19 toxemia, edema and swelling, and that can stretch 20 Glisson's capsule and cause right upper quadrant 21 pain. But just because you have the right upper 22 quadrant pain does not mean that you have a 23 hematoma, but it means you've got to get the baby 24 out as fast as possible. 25 Q. It means you have liver involvement? PREMIER COURT REPORTING 330-494-4990 888-440-1418 71 1 A. That's right. You have liver swelling that can be 2 represented by bleeding also when you get the 3 pain. The transaminase level elevations show us 4 that we already have the hepatocellular 5 degeneration releasing those enzymes. 6 I've had a couple pages. I need to take 7 just a couple minutes. 8 (A short break was taken.) 9 BY MR. FRASURE: 10 Q. Dr. Gatewood, could antihypertensive medications 11 be appropriately ordered over the phone here by 12 Dr. Liu? 13 A. That's correct. 14 Q. But just not the magnesium sulfate? 15 A. That's correct. 16 Q. If Dr. Liu had been told that he must come in and 17 let's say he arrives at 3:20 or thereabouts, 18 that's within about thirty minutes after the 2:50 19 labs come back? 20 A. That's correct. 21 Q. If we have him come in at 3:20, she's not given 22 magnesium sulfate until 3:20, he's giving it then, 23 and we have him start giving antihypertensives at 24 about 3:20, how likely is it that the outcome 25 would have been any different here if that all PREMIER COURT REPORTING 330-494-4990 888-440-1418 72 1 starts at 3:20? 2 A. Well, we know that we didn't get the shoulder 3 cramping until about a half hour after that. And 4 we don't know whether the shoulder -- At the time 5 of the shoulder cramping, you cannot say for sure 6 that that represented strictly hematoma versus 7 capsular swelling secondary to the liver. So 8 getting the pressure under control is the key 9 factor here, and they should have had the pressure 10 under control by that point in time. And more 11 importantly at that point in time he would have 12 been there to do the section as soon as the 13 patient started complaining of the shoulder pain. 14 They had the entire staff there, so he could have 15 effected a section within ten or fifteen minutes 16 at the latest. 17 Q. You mentioned blood-tinged urine around 3:03 from 18 the urinary catheter? 19 A. That's correct. 20 Q. What is the significance of that in your opinion? 21 A. Well, the significance is one of two things, 22 either trauma from the Foley catheter itself being 23 inserted in a situation where you have a HELLP 24 syndrome and a potential DIC or disseminated 25 intravascular coagulation, or it is actually a PREMIER COURT REPORTING 330-494-4990 888-440-1418 73 1 manifestation of renal damage secondary to the 2 HELLP syndrome and/or DIC. It's a very 3 significant finding. 4 Q. In either case? 5 A. Yes, because normally even when you catheterize a 6 bladder you're not going to get blood-tinged 7 urine. You might get microscopic hematuria but 8 not blood-tinged. 9 Q. One of your criticisms against Nurse Nuza is that 10 she did not read the nurse's note that mentioned 11 blood-tinged urine and also shoulder pain. 12 Remember that? 13 A. That is correct, sir. 14 Q. So we know Nurse Burton wrote those down, yet you 15 criticize Nurse Burton for not telling her orally? 16 A. That's correct. That's a very significant 17 finding. 18 Q. In retrospect or at the time? 19 A. At any time. 20 Q. Let's go over specifically in your report, 21 Dr. Gatewood, your criticisms of the nurses. I 22 think it's near the end. 23 MR. HIRSHMAN: Page 7. 24 A. Yes, I have it. 25 Q. Page 7? PREMIER COURT REPORTING 330-494-4990 888-440-1418 74 1 A. Correct. 2 Q. You start out by saying that the nurses in the 3 plural caring for the patient fell below accepted 4 obstetrical care for the following reasons. Let 5 me just paraphrase it. One, failed to require the 6 nurse-midwife to get a physician to come to the 7 hospital to evaluate and manage a critically ill 8 patient; correct? 9 A. That's correct. 10 Q. Number two, failed to properly evaluate the 11 patient's BP and fetal heart tracing in a timely 12 manner? 13 A. That's correct. 14 Q. Number three, failed to inform the nurse-midwife 15 of the blood-tinged urine and shoulder pain. 16 We've been over that. 17 A. Correct. 18 Q. Number four, failed to use the chain of command to 19 assure a physician would come to the hospital no 20 later than 3 a.m. if the nurse-midwife did not 21 require a physician to attend the patient by this 22 time? 23 A. Correct. 24 Q. We've been over that, too; right? 25 A. That's correct. PREMIER COURT REPORTING 330-494-4990 888-440-1418 75 1 Q. And then on the next page you say as a result of 2 these deviations of acceptable obstetrical care, 3 Ms. Wright suffered the complications of severe 4 pre-eclampsia with the HELLP syndrome 5 complications. 6 Have we covered all the criticisms you 7 have of the nurses/hospital? We've covered 8 Dr. Liu. We've covered the nurse midwife. 9 A. Yes, you have, sir. 10 Q. A couple more questions and I think I'm done here. 11 Going back to the fetal heart tracing issue -- 12 Well, before that, let me go to page 3. There's 13 something I don't understand on your notes on page 14 3. I think this is the report. 15 A. Of my report? 16 Q. Yes, sir. Number 15, there's a word or two there 17 on the third line of number 15 that I don't 18 follow. Could you read the whole 15 into the 19 record? 20 A. Sure. The nursing staff did not stay with this 21 critically ill patient to monitor frequent blood 22 pressure checks, reflexes every 30 minutes, and 23 evaluate the fetal heart rate. 24 Q. It was reflexes every 30 minutes that I had a 25 little trouble with. If they had done that, what PREMIER COURT REPORTING 330-494-4990 888-440-1418 76 1 would that have shown and what would have been the 2 significance, if any, of that? 3 A. Well, I think in a patient who has severe 4 pre-eclampsia you're monitoring reflexes to see 5 the degree of central nervous system excitability. 6 And she wasn't on mag sulfate. So by monitoring 7 that, you're going to see that the reflexes are 8 becoming more brisk. She came in with just two 9 plus reflexes. So in all probability the reflexes 10 would have become more brisk, and they also check 11 for ankle clonus. 12 The other thing of it is, we know that the 13 nurses were not in the room when the bradycardia 14 started. As a matter of fact, the one nurse in 15 her deposition even stated that when she saw the 16 fetal heart rate tracing, she was hoping that this 17 would be the mother's heart rate and not the 18 baby's and found out that it wasn't. So under 19 these circumstances, they were not in the room 20 with the patient, and that's unacceptable in a 21 severely ill patient. 22 Q. Not in the room at what critical point? 23 A. At the time the patient is in the hospital, she's 24 not being managed properly. She has a very high 25 blood pressure, she has a HELLP syndrome, and PREMIER COURT REPORTING 330-494-4990 888-440-1418 77 1 they're not in the room physically with the 2 patient doing these things and watching the 3 patient and the reflexes and the monitors and the 4 blood pressures and so forth as I've reiterated. 5 Q. Are you saying that the standard of care requires 6 someone to be basically in the room every minute, 7 the nurse to be in the room every minute? 8 A. With the exception to go out to go to the bathroom 9 or something, but yes, they should be with the 10 patient continuously and certainly not the fifteen 11 or twenty-minute period of time that lapsed when 12 Nurse Burton went out and the other nurse came in 13 and found the fetal heart rate down. 14 Q. What caused the fetal heart rate to go down? 15 Maybe we've covered that, but I want to be sure. 16 A. The heart rate went down for two reasons. Number 17 one, the severe pre-eclampsia reduces placental 18 blood flow by up to 50 percent. And the heart 19 rate went down. Assuming that this patient is now 20 bleeding into the capsule of the liver and now 21 into the abdominal cavity, the heart rate will go 22 down. It's basically a response to hypoxia or 23 decreased oxygenation and perfusion. 24 Q. Of the infant? 25 A. Yes. PREMIER COURT REPORTING 330-494-4990 888-440-1418 78 1 Q. Just out of curiosity, were you surprised with 2 this scenario that the infant survived and is 3 doing well with what happened here? 4 A. I was surprised that there weren't any immediate 5 problems with this child in the nursery due to the 6 length of the deceleration. But if you look -- 7 remember, about a half hour before there was an 8 increase in the heart rate and it dropped and we 9 lost the beat-to-beat and everything else. But 10 babies that suffer an immediate trauma prior to 11 delivery of decreased oxygenation respond rapidly 12 to resuscitative efforts versus babies that have 13 been chronically stressed and then go through a 14 difficult labor where they may have the low Apgars 15 persisting five, ten or fifteen minutes. But in 16 all honesty, I was surprised that this baby did 17 not exhibit symptoms of problems associated -- in 18 the nursery period. It responded rapidly to 19 resuscitative efforts and as a matter of fact 20 didn't even need to be intubated. 21 Q. From my reading, I've seen that the HELLP syndrome 22 can have both maternal and baby morbidity and 23 mortality; correct? 24 A. That's correct. 25 Q. Even when treated appropriately, there's that PREMIER COURT REPORTING 330-494-4990 888-440-1418 79 1 risk? 2 A. There's always that risk. 3 Q. So you believe the baby here did not suffer 4 chronic problems in the labor? 5 A. No. 6 Q. It was rather acute? 7 A. Well, I think the fetal heart tracing demonstrates 8 that we had an acute episode. 9 Q. When do you think the fetal heart tracing -- and 10 point me to it if you can by time or number -- 11 first showed worrisome signs at least that 12 persisted for a few minutes. 13 A. Okay. I've got it right in front of me. 14 Q. And before you go into that, am I correct, Doctor, 15 you need to see at least a persistence for a 16 couple minutes to be sure that the baby isn't just 17 responding to some external pressure or internal 18 pressure? 19 A. Oh, sure, it's persistence, you're correct. 20 Q. When do you see the first persistent problem that 21 should tell someone there's something going on 22 here? 23 A. At approximately twenty minutes after four, 24 fifteen to twenty minutes after four. You see the 25 first significant deceleration at -- I have to PREMIER COURT REPORTING 330-494-4990 888-440-1418 80 1 count this out. 2 MR. HIRSHMAN: Do you have panels there 3 you can use? 4 A. Yes. On panel 39908 at the end of that panel you 5 see the first of the decelerations and then it has 6 a fairly decent recovery. 7 Q. Which line now, top or bottom, just so I'm clear? 8 A. We're looking at the fetal heart rate. Then that 9 starts to show persistence of decelerations, and 10 they're down to the level of 70 to 80 through the 11 next five to ten minutes. Then when you get down 12 to 4:30 you have -- the baseline is running at 13 approximately 70. But this is what I was 14 referring to earlier. You still saw some recovery 15 there back up to 120 but you're getting persistent 16 decelerations. And then the bottom basically 17 falls out when you get to 4:40, 4:35 to 4:40. And 18 from that point on, there's no recovery. 19 Q. Where does the bottom fall out, what panel? 20 A. It would be at the end of the page that has panel 21 39914, right at 39915, the beginning of that. 22 Q. 39915? 23 A. That's right. So as you say, going in with what 24 you had stated, you see a persistence and an 25 increasing degree of problems on this monitor PREMIER COURT REPORTING 330-494-4990 888-440-1418 81 1 tracing. And then as I say, you would basically 2 say the bottom fell out at that point and it 3 stayed down. 4 Q. So the persistence starts to trouble you around 5 4:30? 6 A. Right. 7 MR. FRASURE: Let me just look over my 8 notes and I think we're done. 9 - - - - - - - 10 FURTHER CROSS-EXAMINATION 11 BY MR. PARKER: 12 Q. Dr. Gatewood, what are your duties currently at 13 the Oberlin Medical Center besides patient care? 14 A. I'm the chairman of the department of obstetrics 15 and gynecology. So as part of that, I am on 16 several committees, the medical executive 17 committee, I am in charge of the OB division, I'm 18 on the operating committee, and I'm on the 19 performance -- it's kind of like the peer review 20 or quality assurance committee. 21 Q. What percentage of your professional time is 22 involved in those kinds of administrative duties? 23 A. Actually as far as total time, because I work so 24 many hours here, it would probably be five percent 25 or less. PREMIER COURT REPORTING 330-494-4990 888-440-1418 82 1 Q. And what percentage of your professional time is 2 engaged in medical-legal reviews, testimony? 3 A. I do this strictly on my time off. 4 Q. So you consider that zero percentage of your 5 professional time? 6 A. Yes. 7 Q. Do you teach anywhere currently? 8 A. No, sir. 9 Q. Have you contributed to the medical literature? 10 A. No, sir. 11 Q. You expressed some opinions when Mr. Frasure was 12 asking questions, you expressed opinions about 13 rules requiring the physician to personally 14 evaluate a patient before administering magnesium 15 sulfate. What rules are you referring to? 16 A. It's in the policies and procedures, 17 administration of Pitocin -- I keep saying 18 Pitocin, I'm sorry, administration of magnesium 19 sulfate in the St. Luke's Hospital rules and 20 regulations. 21 Q. And are those the only rules you're referring to 22 when you talk about rules requiring the physician 23 to personally evaluate the patient? 24 A. Well, we're only discussing here with this 25 hospital under these circumstances. But we have PREMIER COURT REPORTING 330-494-4990 888-440-1418 83 1 the same policy. Hospitals have the policy that 2 patients must be evaluated by a physician prior to 3 the institution of mag sulfate. Now, I could not 4 sit here and say that every single hospital in the 5 United States has that. 6 Q. That's fine. I just want to make sure that those 7 are the rules you're referring to -- 8 A. That's correct. 9 Q. -- when expressing your opinion. 10 A. Sure. 11 Q. I want to make sure I understand a couple of 12 definitions here. You've been using the term 13 Glisson's capsule. Do I understand that to be 14 that portion of the peritoneum that surrounds and 15 encapsulates the liver? 16 A. It's the capsule surrounding the liver, the 17 outer-most layer of the liver. 18 Q. When we use the word liver rupture in connection 19 with this case, are we actually more precisely 20 talking about a tear or a leakage or a breach of 21 that capsule? 22 A. Well, no. The liver may rupture and the capsule 23 may remain intact and tamponade or stop the 24 bleeding. 25 Q. Well, that's what I'm trying to find out in this PREMIER COURT REPORTING 330-494-4990 888-440-1418 84 1 case, because I've heard the term rupture applied 2 to both. 3 A. In this case based on the operative report, there 4 was a hematoma of Glisson's capsule that over on 5 the left lobe appeared to have been breached or 6 ruptured. The capsule ruptured and now allowed 7 the bleeding into the abdominal cavity. And 8 that's why, when they opened her up, they saw the 9 dark red blood. It was from that. 10 Q. In this case we -- and by we I mean the lawyers, 11 at least myself -- have often used the term liver 12 rupture, but I think more technically in this case 13 we're talking about a capsular rupture that spills 14 the contents of the hematoma, aren't we? 15 A. Well, the liver ruptured. You know, I don't want 16 you to confuse it as a bursting out. The liver 17 cracks. And if you've eaten liver, you've seen -- 18 the texture of liver is different than beef or 19 something. 20 Q. Sure. 21 A. So the liver itself with the swelling and then 22 with the bleeding around the periportal regions, 23 then you get enough pressure building that it 24 actually just cracks open. It's not like a ragged 25 edge blowout. And then that's when the massive PREMIER COURT REPORTING 330-494-4990 888-440-1418 85 1 bleeding can begin. And when you read the 2 operative report, you'll see where they tried to 3 suture the edges and then they packed the defects. 4 That's how you treat it. 5 Q. Fair enough. Do you think there was probably some 6 liver bleeding before the shoulder pain was 7 experienced around 3:50? 8 A. Well, there had to be some degree, something 9 swelling, the liver swelling or bleeding to 10 distend Glisson's capsule. 11 Q. I want to see if I understand this correctly. The 12 shoulder pain, assuming it came from the liver, 13 could be from pressure of the bleeding and 14 hematoma within the capsule? 15 A. Correct. 16 Q. Could it also be from free blood seeping into the 17 peritoneum causing irritation? 18 A. That was my next statement. That is absolutely 19 correct. 20 MR. PARKER: I think that's all I have. 21 - - - - - - - 22 FURTHER CROSS-EXAMINATION 23 BY MR. FRASURE: 24 Q. Doctor, a couple questions I forgot to ask you. 25 Why was it you left Akron and went to Oberlin? I PREMIER COURT REPORTING 330-494-4990 888-440-1418 86 1 need to just ask you that. 2 A. My lease was up, and rather than sign another 3 four-year lease, my wife and I wanted to go look 4 in small towns. I looked all over the midwest and 5 decided that Oberlin was a great town because I 6 still had two little kids. So that was the basic 7 reason. I did not leave under any duress or 8 demand. 9 This is perfect timing. I just got a 444 10 page, which means STAT. 11 Q. You don't have any criticism of the actual 12 C-section itself during the procedure; right? 13 A. No, sir, I do not. 14 MR. FRASURE: Thank you, Dr. Gatewood. 15 - - - - - - - 16 (The deposition was concluded at 6:15 p.m.) 17 - - - - - - - 18 19 20 21 22 23 24 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418 87 1 W I T N E S S C E R T I F I C A T E 2 3 I, PAUL D. GATEWOOD, M.D., do hereby certify that 4 I have read my deposition taken on October 27, 2000, in 5 the case of G. Delores Savage, as Legally Appointed 6 Guardian for Wanda Wright, an Incompetent, et al., vs. 7 Columbia/HCA Healthcare Corp., et al., consisting of 8 eighty-eight pages, and that said deposition is a true 9 and correct transcription of my testimony. 10 11 ________________________________ Paul D. Gatewood, M.D. 12 13 Dated this ______ day of ________________, 20____. 14 15 16 Sworn to and subscribed before me this ______ 17 day of ______________, 20____. 18 19 ________________________________ 20 Notary Public 21 My commission expires _______________________. 22 23 - - - - - - - 24 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418 88 1 C E R T I F I C A T E 2 STATE OF OHIO, ) ) SS: 3 STARK COUNTY. ) 4 I, Linda McAnallen, a Stenographic Reporter and 5 Notary Public in and for the State of Ohio, duly 6 commissioned and qualified, do hereby certify that the 7 within-named Witness, PAUL D. GATEWOOD, M.D., was first 8 duly sworn to testify the truth, the whole truth and 9 nothing but the truth in the cause aforesaid; that the 10 testimony so given by him was by me reduced to 11 Stenotype in the presence of the witness; and that the 12 foregoing is a true and correct transcription of the 13 testimony so given by him as aforesaid. 14 I certify that this deposition was taken at 15 the time and place in the foregoing caption specified. 16 I further certify that I am not a relative, 17 counsel or attorney of either party nor otherwise 18 interested in the event of this action. 19 IN WITNESS WHEREOF, I have hereunto set my hand 20 and affixed my seal of office at North Canton, Ohio, 21 this 8th day of November, 2000. 22 23 _____________________________________ Linda McAnallen, Notary Public 24 My commission expires August 20, 2005. 25 PREMIER COURT REPORTING 330-494-4990 888-440-1418