1 1 2 STATE OF OHIO 3 COUNTY OF CUYAHOGA 4 IN THE COURT OF COMMON PLEAS 5 CASE NO. 374280 6 -----------------------------------------x 7 G. DELORES SAVAGE, as legally 8 appointed Guardian for WANDA 9 WRIGHT, an incompetent, et al, 10 Plaintiffs, 11 - against - 12 COLUMBIA/HCA HEALTHCARE CORP., et al., 13 Defendants. 14 -----------------------------------------x 15 November 21, 2000 3:30 p.m. 16 17 18 Deposition of MARTIN L. 19 GIMOVSKY, M.D., taken by the Plaintiffs, 20 held at the Kinko's Videoconferencing 21 Center, 16 East 52nd Street, New York, New 22 York, before Joseph Ravenell, a Court 23 Reporter and Notary Public of the State of 24 New York. 25 2 1 2 A P P E A R A N C E S : 3 4 LINTON & HIRSHMAN, ESQS. Attorneys for Plaintiffs 5 Hoyt Block, Suite 300 700 West St. Clair Avenue 6 Cleveland, Ohio 44113-1230 BY: TOBIAS H. HIRSHMAN, ESQ. 7 (By Videoconference) STEPHEN KEEFE, ESQ. 8 (By Videoconference) 9 10 BUCKINGHAM, DOOLITTLE & BURROUGHS, LLP 11 Attorneys for Defendants COLUMBIA/ST. LUKE'S MEDICAL 12 CENTER and NURSE BURTON 4518 Fulton Drive, NW 13 Canton, Ohio 44735-5548 BY: CHRISTOPHER HUMPHREY, ESQ. 14 (By Videoconference) 15 16 REMINGER & REMINGER, ESQS. 17 Attorneys for Defendants DR. GYVES and NURSE/MIDWIFE NUZA 18 The 113th St. Clair Building Cleveland, Ohio 44114 19 BY: ALAN B. PARKER, ESQ. 20 21 22 23 24 25 3 1 2 3 M A R T I N L. G I M O V S K Y, 4 having first been duly sworn by a Notary 5 Public of the State of New York, was 6 examined and testified as follows: 7 EXAMINATION BY 8 MR. HIRSHMAN: 9 Q. Good afternoon. 10 A. Good afternoon. 11 Q. My name is Toby Hirshman. I'm 12 going to be asking you some questions 13 today about a medical malpractice case 14 that you have been retained as an expert 15 in. Let's start with a very basic 16 question. Your full name? 17 A. Martin L. Gimovsky. 18 Q. And I've got an address for you 19 on a CV that I have of 1522 Packlind 20 Place. Is that your address? 21 A. That hasn't been my address for 22 several years. 23 Q. Okay. That's a Missouri 24 address, as I see here. 25 A. Yes. 4 1 GIMOVSKY 2 Q. Can you give us your home 3 address? 4 A. 80 John Street, New York, New 5 York 10038. 6 Q. When did you move to New York? 7 A. Last year. 8 Q. 1999? 9 A. Yes, sir. 10 Q. What month? 11 A. July of 1999. 12 Q. Let's start by having you detail 13 the materials that you have reviewed in 14 formulating your opinions in regard to 15 this case. And before you do that, let me 16 look at your letter. Your letter suggests 17 you looked at records from St. Luke's as 18 well as the depositions of Dr. Liu and 19 Dr. Gyves as well as Nurses Nuza and 20 Burton as well as reports of Dr. Tucker 21 and Dr. Gatewood. What else, if anything, 22 have you reviewed? 23 A. I read those two expert 24 reports. I reviewed Wanda Wright's 25 St. Luke's Medical Center records from 5 1 GIMOVSKY 2 1998. I read deposition testimony from 3 Dr. Liu, Dr. Gyves, Nurse Nuza and Nurse 4 Burton. And I have expert reports from 5 Dr. Tucker, who is a neurologist, and 6 Dr. Gatewood, who is an 7 obstetrician/gynecologist. 8 Q. Have you reviewed anything else? 9 A. No, sir. 10 Q. All right. I've heard your name 11 before. I know you have functioned in 12 this capacity before. Can you give me 13 some idea as to the number of cases that 14 you have been involved with as a 15 medicolegal expert? 16 A. I've been reviewing cases since 17 I finished my fellowship in 1983, and I 18 review on average six to 12 cases a year 19 over that time span. 20 Q. And how often do you actually 21 give deposition testimony? 22 A. Over 17 years, I've given many 23 depositions. So it kind of varies with 24 the time. I would say I've been deposed 25 40 or 50 times. 6 1 GIMOVSKY 2 Q. And how many times have you 3 appeared in trial either personally or by 4 videotape? 5 A. Eight or nine. 6 Q. You have done work for 7 plaintiffs and defendants, I've noticed. 8 Can you break down how that split goes for 9 you? 10 A. When I first started to review 11 records, all the cases I was asked to look 12 at were defense. And then several years 13 later, it all shifted to plaintiff. And 14 now it's about 50/50. 15 Q. I note you have worked for the 16 Reminger firm before. Can you tell me how 17 many times you have done that? 18 A. Just a few cases. Not a lot of 19 cases that I can recall. Not in the past. 20 Q. More than five? 21 A. Of all the records I've ever 22 reviewed for Reminger & Reminger? Is that 23 the question? 24 Q. Yes. 25 A. I would say probably five or 7 1 GIMOVSKY 2 six. 3 Q. All right. Have you ever been 4 involved as a medical expert in a HELLP 5 syndrome case before? 6 A. Yes, once previously. 7 Q. Can you tell me how long ago? 8 A. Must be a while. I don't 9 remember. Must be more than five years. 10 Q. Can you tell me where that case 11 was? 12 A. The lawyer was in Washington, 13 D.C. That's really all I remember. 14 Q. Do you remember his name? 15 A. No. But I might be able to find 16 out. 17 Q. All right. Was it a plaintiff's 18 case or defense case? 19 A. I was asked to review the 20 records for the plaintiff. 21 Q. And did you write a report? 22 A. I don't remember. 23 Q. Did you testify by deposition or 24 otherwise? 25 A. I think I gave a deposition in 8 1 GIMOVSKY 2 that case. 3 Q. The lawyer was from D.C. Do you 4 know whether the case was in D.C.? 5 A. I think the case was in 6 Virginia. I don't remember exactly. I 7 don't think it was in Washington, D.C. I 8 think just the attorney was in D.C. 9 Q. Do you recall the circumstances 10 that arose or what the issues were in that 11 case? 12 A. To some extent. 13 Q. Can you let me know, give me 14 some insight into what they were? 15 A. It was a patient who had 16 severely elevated liver enzymes who 17 subsequently died at an outlying 18 hospital. And the contention was that if 19 the patient had been diagnosed earlier and 20 transferred to one of the medical centers, 21 the outcome would have been different. 22 Q. What was the cause of death? 23 A. I don't remember exactly. I 24 just remember that the enzymes were 25 elevated into the 20,000 range, and the 9 1 GIMOVSKY 2 patient died immediately after transfer, 3 immediately during transfer, something 4 like that. It's a while back. 5 The patient had elevated, 6 massively elevated liver enzymes. So in 7 that regard, that was really the key part 8 of the case. And whether or not she 9 should have been transferred earlier or 10 not was the contention. I don't have the 11 specific details. It was many years ago. 12 Q. You don't recall whether there 13 was subcapsular hematoma of the liver? 14 A. I don't remember specifically. 15 One would presume there was some kind of 16 liver pathology. I don't remember offhand 17 the details of it, though. I hadn't 18 really thought about it in terms of this 19 case. 20 Q. And your testimony for the 21 plaintiff was that a more expeditious 22 transfer should have taken place? 23 A. Yes, it was. 24 Q. And your testimony was that had 25 a more expeditious transfer taken place 10 1 GIMOVSKY 2 that this woman would have survived? 3 A. That the outcome would have been 4 materially changed. 5 Q. Okay. In other words, women 6 with HELLP syndrome can be treated? 7 A. Absolutely. We treat them every 8 day. 9 Q. Successfully? 10 A. By and large. 11 Q. Let's talk about the nature of 12 your practice. I note that you have been 13 in Missouri and now you are in New York. 14 I believe there were a few other places 15 where you practiced before? 16 A. Yes, sir. 17 Q. Missouri, if I'm not mistaken? 18 A. Yes. 19 Q. Has your practice been 20 essentially of the same nature in each of 21 those positions that you have held? 22 A. Yes. My practice has been 23 predominantly high-risk and normal 24 obstetrics, with some ambulatory 25 gynecology. Ever since I've been in 11 1 GIMOVSKY 2 practice. 3 Q. When you say ambulatory 4 gynecology, what does that mean? 5 A. Well, I have always had an 6 interest in clinics and I've spent a lot 7 of time in them providing primary care and 8 taking care of routine health issues in 9 clinic. That's been my other interest 10 other than obstetrics. 11 Q. So how much of your practice is 12 gynecologic versus obstetric? 13 A. It's just a very small amount. 14 Most of my clinical practice is 15 obstetrics. The vast majority. 16 Ninety-five percent of it. 17 Q. You have been in an academic 18 setting for some time? 19 A. I've been at community hospitals 20 that are organized on academic 21 principles. But I've always been in big 22 community hospitals. 23 Q. Has your practice been in 24 hospitals with residency programs in 25 obstetrics and gynecology? 12 1 GIMOVSKY 2 A. All except -- actually my first 3 practice when I finished residency was in 4 a hospital that was very small and didn't 5 have a training program. But since my 6 fellowship in 1983, I've always been in 7 hospitals that have training programs. 8 Q. And you are now at a hospital by 9 the name of? I'll find it here. 10 A. That's okay. I'll fix it. It's 11 wrong there. 12 Q. Oh, is it? 13 A. Yes. That hospital went 14 bankrupt. So I'm now -- 15 Q. Brookdale? 16 A. Yes, Brookdale went bankrupt a 17 few months ago. So I'm now chief of 18 OB/GYN for Jacobi Medical Center and North 19 Central Bronx Hospital up in the Bronx. 20 Q. Brookdale University Hospital 21 Medical Center was an institution that was 22 freestanding or was it associated with 23 some other institution? 24 A. No, it was a freestanding 25 private hospital in a very poor part of 13 1 GIMOVSKY 2 town. And these are very tough times in 3 medicine. 4 Q. Did it have a residency program 5 when it closed in obstetrics and 6 gynecology? 7 A. It still does, yes. It's in the 8 process, I guess, of being re-evaluated by 9 whoever is the new management. But we had 10 an independent training program, yes. 11 Q. So the hospital is still 12 functioning. It's just in bankruptcy? 13 A. Yes. 14 Q. Meaning that it's in Chapter 11 15 or something that allows it -- 16 A. No, I don't think they do it 17 that way. It's way too complex. What 18 they did is they fired all the trustees 19 and replaced the management and they are 20 trying to figure out what to do. Their 21 debt is enormous. And so their ability to 22 keep and train and have a good medical 23 staff has been severely jeopardized. The 24 doors are still open. 25 Q. Okay. Have you worked with 14 1 GIMOVSKY 2 nurse-midwives in your various 3 incarnations? 4 A. Yes, sir. I have. 5 Q. Do you work with them right now 6 at Jacobi? 7 A. Yes. At Jacobi and North 8 Central Bronx, I have about 30 midwives on 9 my staff and about 25 or 30 10 obstetricians. So they make up almost 11 half of the professional staff. 12 Q. So you have a residency program 13 plus nurse-midwives? 14 A. Plus physicians' assistants, 15 yes. All the different types of people. 16 Q. All right. I take it at all 17 times during the day, there are physicians 18 that are staffing the obstetrics 19 department? 20 A. Including myself, yes, sir. 21 Q. How many cases of HELLP syndrome 22 do you see in a given year? 23 A. I would say it's not uncommon. 24 Somewhere around seven to ten percent of 25 all pregnancies are complicated by 15 1 GIMOVSKY 2 hypertension and preeclampsia. And some 3 small fraction of that have HELLP 4 syndrome. So I would say we have about 5 four to five thousand deliveries. We 6 probably see one to two cases a month on 7 average. 8 Q. How often have you had occasion 9 to see patients with HELLP syndrome 10 complicated by subcapsular hematoma of the 11 liver? 12 A. To the extent that the liver 13 ruptured or -- 14 Q. No. 15 A. -- without the liver rupturing? 16 I've seen several cases where at 17 Cesarean section, we felt a tense liver. 18 And with the abnormal enzymes, I think I 19 could presume that that reflects 20 subcapsular hematoma. I don't think I've 21 seen a case, certainly not in the past 22 decade, where there was a ruptured liver. 23 Q. So let's start with -- so the 24 last ten years, what you are telling me is 25 that you have seen cases of hepatic 16 1 GIMOVSKY 2 hemorrhage, none of them ruptured? 3 A. I've seen cases of hepatic 4 involvement that I would presume would be 5 hemorrhage, because we only indirectly 6 make the diagnosis. But I haven't seen a 7 case of a ruptured liver. 8 Q. In ten years? 9 A. Yes. 10 Q. Or ever? 11 A. I can't remember ever seeing a 12 case. I'm not convinced that that would 13 be true, but I certainly haven't seen a 14 case of a ruptured liver in the last ten 15 years. 16 Q. How about going back to the 17 beginning of your practice? 18 A. I can't specifically remember a 19 case. I can certainly -- I've seen cases 20 of hemoperitoneum at C-section, which is 21 how this patient presented at some level. 22 But not due to hepatic rupture. Due to 23 other things. 24 Q. All right. Did you give me a 25 number as to how many you had seen with 17 1 GIMOVSKY 2 hepatic involvement? I don't think you 3 did. I didn't write it down, if you did. 4 A. A handful. It's impossible to 5 know exactly. I'm called in to a lot of 6 cases in which I'm the consultant. I 7 don't know exactly how many cases would 8 have had tense liver. Certainly a 9 handful, I would say. 10 Q. A handful to me means five to 11 ten. Is that about what you are thinking? 12 A. Yes. I would think five to ten 13 cases or five cases, somewhere in that 14 range, over the past ten years. 15 Q. Of those handful, can you tell 16 me how many of those women have died? 17 A. None of the patients that 18 have -- 19 Q. Rather than using the past 20 perfect tense -- present perfect tense, 21 how many of those women died as a result 22 of their condition? 23 A. I can't think of any that died 24 as a result of that condition. 25 Q. Can you tell me how many of them 18 1 GIMOVSKY 2 sustained devastating central neurologic 3 deficits as a result of that condition? 4 A. I would estimate that it was one 5 or two of them did sustain some injuries. 6 But I don't have the specific cases. I 7 couldn't tell you anything more than 8 that. But nobody died as a result of a 9 hepatic rupture, at least not to my 10 knowledge. 11 Q. When you say some of them, one 12 to two had sustained some injuries, my 13 question to you was how many of them 14 sustained central nervous system injuries 15 that left them in a let's call it a 16 chronic vegetative state? 17 MR. PARKER: Objection. Are we 18 talking now about patients with hepatic 19 involvement, which is what I thought we 20 were originally talking about? 21 MR. HIRSHMAN: That's exactly 22 what we are talking about. We are talking 23 about hepatic involvement, since he has 24 seen none with hepatic rupture. 25 MR. PARKER: That's fine. 19 1 GIMOVSKY 2 That's what I thought. But then the last 3 answer had me confused. 4 A. I can't think of any that had 5 central nervous system sequelae, if that's 6 what your question is, associated with a 7 subcapsular hemorrhage. 8 Q. Okay. That was my question. 9 Can you tell me how many of them 10 may have suffered from other long-term 11 morbidities? You mentioned one to two had 12 some injury. I guess I'm asking you to 13 define for me what you recall those 14 injuries as being. 15 A. I don't recall specifically. I 16 really don't. I'm just trying to give you 17 my best estimate of what my sense is of 18 the patients I've seen. 19 Q. I appreciate that. 20 When dealing with this subject 21 matter that we are talking about here, 22 meaning HELLP syndrome, HELLP syndrome 23 with subcapsular hematoma, HELLP syndrome 24 with rupture, liver capsule due to 25 subcapsular hematoma, what texts do you 20 1 GIMOVSKY 2 find to be of help in dealing with these 3 issues? 4 A. I think that there is so little 5 in terms of the experience that's modern 6 available that I would go to Williams' 7 Obstetrics if I was going to look for any 8 one text. I have some specialized books 9 on gastrointestinal-type diseases in 10 pregnancy. But they would be a second 11 choice. 12 Q. How about Gabbe? 13 A. Steve Gabbe's book? 14 Q. Yes. 15 A. That would be a good source. I 16 don't think anybody has enough cases to be 17 authoritative in a legal case. But that's 18 certainly helpful. Gabbe's book is 19 helpful. But I would go to Williams. 20 Q. How about Sibai? 21 A. Sibai is an expert on the 22 subject too. I don't know which book he 23 has written those chapters in. But I 24 certainly would take what he has written 25 as the largest experience I could think of 21 1 GIMOVSKY 2 of women who have very severe disease and 3 complications from it. 4 Q. How about Creasy and Resnick? 5 A. Nothing special about Creasy and 6 Resnick that I would use this subject 7 for. If I was going to actually try to 8 access some information, I would go to 9 Medline and look for Sibai. 10 Q. Who provides your malpractice 11 coverage? 12 MR. PARKER: Objection. You can 13 answer. 14 A. I don't know. 15 Q. That's a nice way to be. 16 A. I work for the City of New York. 17 Q. Have you ever had any 18 associations with Columbia? 19 A. University? Only Columbia 20 University as a student. 21 Q. That's not the Columbia I'm 22 thinking of. 23 A. I haven't had associations with 24 Columbia/HCA. That's what you are talking 25 about, right? 22 1 GIMOVSKY 2 Q. That's correct. Do you know 3 Dr. Gyves? 4 A. No. 5 Q. Do you know Dr. Sam Liu? 6 A. No, sir. 7 Q. At least not from anything you 8 have gathered from reviewing these 9 records? 10 A. Yes, sir. 11 Q. In your opinion, did Wanda 12 Wright become eclamptic? 13 A. Wanda Wright had by definition I 14 think severe preeclampsia. I realize she 15 didn't regain consciousness after her 16 Cesarean section. So you could argue that 17 if you wanted to make the diagnosis of 18 eclampsia, perhaps her unresponsive state 19 makes that diagnosis. My working 20 diagnosis on her would be that she had 21 severe preeclampsia. 22 Q. So what you are saying is that 23 you can't rule out a scenario where her 24 failure to regain consciousness was due to 25 seizure activity? 23 1 GIMOVSKY 2 A. I don't think she had any 3 seizure activity. One of the criteria for 4 diagnosing eclampsia is coma; not 5 convulsion but coma. So indeed if she 6 never regained consciousness, perhaps some 7 people might see that as being symptomatic 8 of eclampsia in a case like this. 9 Personally I saw this case as a case of 10 severe preeclampsia and I was just trying 11 to be all-inclusive. 12 Q. What do you see as the cause of 13 her central nervous system injury? 14 A. I would think that the most 15 likely cause of her injury was alternating 16 hyper- and hypotension. She had 17 hypertension prior to the surgery. She 18 had general anesthesia, which has a 19 tendency to increase blood pressure, 20 certainly during intubation. And she had 21 a major operation and drainage of her 22 liver during the Cesarean, after the 23 Cesarean, which would predispose her to 24 hypotension. 25 So I think alternating hyper- 24 1 GIMOVSKY 2 and hypotension certainly is well 3 recognized as being able to cause 4 devastating central nervous system injury, 5 and that would be my first estimate as to 6 what the cause was of her CNS problem. 7 Q. Let me see if I can understand 8 this correctly. Wanda came into the 9 hospital with a significantly elevated 10 blood pressure, did she not? 11 A. Yes, sir. 12 Q. Do you remember what those blood 13 pressures were? 14 A. She had blood pressure of 15 207/100. And then she had a repeat blood 16 pressure of 217/112. Those were her first 17 two blood pressures in the hospital. 18 Prenatally her blood pressures 19 were unremarkable. They were in the range 20 of less than 120/80. So she had an acute 21 and severe increase in her blood pressure 22 on admission to St. Luke's Hospital. 23 Q. You are aware, I presume, of the 24 blood pressure at three o'clock in the 25 morning of 195/14 and the one at four 25 1 GIMOVSKY 2 o'clock of 206/111? 3 A. Yes, sir. I have them right 4 here. 5 Q. Okay. And I presume you are 6 also aware of the blood pressure described 7 by the anesthesiologist preoperatively of 8 207/100? Excuse me. I've got on one page 9 it says 207/100. And then on the next 10 page of the anesthesia record, I have 11 210/100. Do you see those? 12 A. I think he copied the 207/100 13 from the previous history. And the second 14 one is probably his blood pressure. I 15 don't have all the -- 16 Q. In other words, the 207/100 may 17 have been a -- 18 A. That's the triage blood 19 pressure, the one at 0055 in the morning. 20 Then that other blood pressure I think is 21 when he started giving her anesthesia. 22 Q. 210/100? 23 A. Yes. 24 Q. Okay. With a pulse of 120. 25 MR. PARKER: Is that a 26 1 GIMOVSKY 2 question? 3 MR. HIRSHMAN: No, that's not a 4 question. I'm just trying to get 5 everybody oriented here. 6 Q. So you have indicated that she 7 was hypertensive. Would you describe that 8 as severe hypertension or what kind of 9 adjective would you apply to that level of 10 hypertension? 11 A. I call that severe hypertension. 12 Q. And then at some point 13 intraoperatively, she became hypotensive. 14 And if I understand correctly, you have 15 suggested that hypotension in the face of 16 preexisting hypertension is more injurious 17 than hypotension when preceded by a normal 18 tensive situation? 19 A. Okay. Yes, I think that's what 20 I said. What I said was that because of 21 the hypertension, the hypotension was that 22 much more injurious. I think that's what 23 you just said. 24 Q. Okay. You have said it better 25 than me. 27 1 GIMOVSKY 2 A. Okay. Well, I spent a lot of 3 years learning it. 4 Q. You indicate in your report that 5 Wanda suffered a stroke, I believe; is 6 that correct? 7 A. That's what my report says. 8 Q. Is that still your opinion? 9 A. I don't have her records right 10 in front of me right now. And so I can 11 only go by what I had written previously 12 as my estimate. 13 By stroke, certainly what I was 14 referring to was the neurologic problems 15 that she suffered. I can't comment 16 further. I don't have the other records 17 here in front of me. 18 Q. Okay. Are you suggesting by 19 stroke that there was some sort of a focal 20 ischemic event? 21 A. No. The reason I wrote that, if 22 I remember correctly, was I was really 23 suggesting that there was a massive 24 central nervous system problem. And I 25 used stroke really in its generic usage 28 1 GIMOVSKY 2 there. I was not referring to a specific 3 diagnosis of a CVA or something like 4 that. I used stroke in the other context. 5 Q. So you are using stroke not to 6 mean a focal ischemic event or a focal 7 hemorrhagic event. But in the sense that 8 you are using it, it could include a 9 global central nervous system event? 10 A. The term for me in this case 11 means something that came out of the 12 blue. It's a temporal term. The patient 13 had a normal neurologic or what looked 14 like a normal neurologic exam before her 15 C-section and then failed really to regain 16 full consciousness afterwards. And based 17 on my understanding of her blood pressures 18 and what likely happened there, I used the 19 word "stroke" in that way. I didn't use 20 it to describe a bleed or an infarct or an 21 emboli. 22 Q. So as you are using the word 23 "stroke," what you mean to convey is the 24 existence of a global central nervous 25 system injury brought on by a hypotensive 29 1 GIMOVSKY 2 event preceded by a hypertensive event? 3 A. Inartfully phrased, perhaps, but 4 yes, that's the point I'm trying to make. 5 Q. And that's your opinion to a 6 reasonable medical probability? 7 A. Based on the records I reviewed, 8 yes. 9 Q. Based on the records you 10 reviewed, would you agree that Wanda 11 suffered from severe preeclampsia that was 12 readily so diagnosable at the time of her 13 admission -- at the time of her 14 presentation to the hospital? 15 MR. PARKER: Objection. You can 16 answer. 17 A. Yes, I would agree with you. 18 Q. And would you agree that by 2:50 19 in the morning -- first of all, would you 20 agree that it was at 2:50 that the 21 laboratory results came back showing 22 elevated liver enzymes and reductions in 23 platelet counts? 24 A. I have 2:45 as when the liver 25 function tests were increased and the 30 1 GIMOVSKY 2 platelet count was 93,000. 3 Q. They were within five minutes of 4 each other, at any rate? 5 A. Right. 6 Q. You would agree with me that at 7 that point she was readily diagnosable and 8 should have been diagnosed as having HELLP 9 syndrome? 10 A. Yes, I do. 11 Q. Okay. Do you believe in 12 classifying HELLP syndrome by the severity 13 of the platelet dysfunction? Not 14 dysfunction. By the platelet decline? 15 A. Well, there is a platelet 16 dysfunction as well as a platelet 17 numerical change. So you are really right 18 on both counts. 19 No, there is a disease process. 20 I don't classify them any differently. 21 HELLP syndrome is a very severe variant of 22 severe preeclampsia. I don't further 23 break it down. 24 Q. I understand some people do. I 25 guess you are not one of them. 31 1 GIMOVSKY 2 From reading the various 3 materials that you have read, would it be 4 fair to say that Wanda was suffering from 5 epigastric pain? 6 A. The note, the original notes at 7 1:45 in the morning said she presented 8 generally not feeling well. And so I 9 don't know whether or not that 10 specifically referred to abdominal pain. 11 I noticed the comments in the nursing 12 notes and the nursing admission about 13 whether or not she had abdominal pain. 14 If you look in the obstetric 15 admission record, there is a comment where 16 it says "Assessment GI." And I saw there 17 where it said "nausea," which I would 18 associate with perhaps abdominal pain. 19 But I don't notice anything that says 20 anything about epigastric pain per se. 21 She presented with a headache 22 that she had had all day, with pedal edema 23 and generally not feeling well, if I look 24 at the chief complaint that Nurse Nuza 25 wrote for 1:45 in the morning. 32 1 GIMOVSKY 2 Q. So whether she had abdominal 3 pain or not or epigastric pain or not, do 4 you have an observation to make on that or 5 are you kind of in the dark on it? 6 A. Well, I think that if Nurse Nuza 7 went to the trouble to ask the question 8 about the headache and the swelling and 9 wrote the blood pressure was 207/100, it 10 would be my assumption, although I don't 11 remember specifically, that she would have 12 asked about the other signs and symptoms 13 of preeclampsia, one of which would be 14 epigastric pain. Although she did not 15 note the pertinent negative to be able to 16 document that. 17 So I don't know other than what 18 is written here what she actually asked. 19 So there is no way I could tell. There is 20 no comment that her abdomen was tender and 21 there is no comment that there was 22 epigastric pain. Just nausea. 23 Q. Is it of any significance to us 24 in our discussion of this case, is it 25 important for us to know whether she had 33 1 GIMOVSKY 2 epigastric pain or not in making 3 determinations as to what further 4 follow-up is needed? 5 A. Well, if she had epigastric 6 pain, it would argue that she had an 7 ongoing liver process presumably or it 8 might argue that. And that might play 9 some role in here. 10 But I think she would have had 11 the same treatment. They would have 12 checked her liver function tests whether 13 she had epigastric pain or not. 14 In terms of the index of 15 suspicion for that kind of problem and the 16 level of severity, I don't think it would 17 have changed what Nurse Nuza did. 18 Q. You mentioned that not only did 19 she have a reduced platelet count but 20 there was also platelet dysfunction. How 21 do you know that? 22 A. Well, patients who have 23 preeclampsia have an imbalance of 24 prostaglandins. And one of those 25 prostaglandins, prostacyclin, plays a role 34 1 GIMOVSKY 2 in how platelets actually aggregate. So 3 she had decreased number. And it's fairly 4 well agreed to by most people who are 5 knowledgeable on HELLP syndrome that we 6 have platelet dysfunction to some extent 7 in addition to a low platelet count. So 8 you have both problems. 9 Q. And does that combination of 10 reduced platelet count and platelet 11 dysfunction lead to a situation where 12 Wanda was suffering from a coagulopathy 13 pre C-section? 14 A. I don't think she had a 15 coagulopathy pre C-section, because when 16 we use the term "coagulopathy," at least 17 as clinicians, we mean bleeding from a 18 site abnormally. She had certainly a 19 predisposition to bleed. And after her 20 surgery, she clearly had a coagulopathy. 21 That's generally what we see. 22 The clotting agents in the blood 23 are consumed when you have a big blood 24 clot like she had in the liver. So that 25 predisposes to the coagulopathy. 35 1 GIMOVSKY 2 It's very unusual to see a 3 patient bleeding from her gums or from the 4 IV site just on the basis of 5 coagulopathy. So I don't think she had a 6 clinical coagulopathy. I think she was at 7 high risk to have DIC, which is what she 8 ultimately did have. 9 Q. Is it your opinion that she was 10 bleeding into her liver based on 11 everything we know? 12 MR. PARKER: When? 13 MR. HIRSHMAN: Preoperatively. 14 A. I think based upon what we know, 15 she had a subcapsular bleed prior to her 16 Cesarean section. 17 Q. Well, is it your impression that 18 her subcapsular hematoma is the result of 19 an intraparenchymal bleed in the liver? 20 A. Well, I think what you have when 21 you have severe preeclampsia and a hepatic 22 bleed is you have a combination of both 23 hypertension and the little blood vessels, 24 the arterioles, spasm. Then you have this 25 propensity to bleed. 36 1 GIMOVSKY 2 So to be able to separate out 3 the blood pressure as a cause and the 4 coagulopathy tendency as a cause I think 5 is a moot point. Both of those factors 6 lead to the risk of having a subcapsular 7 hematoma. When it occurred in this case 8 is not possible for me to be able to 9 delineate based on what I know. Only that 10 it occurred prior to her delivery, because 11 the capsule was ruptured and there was 12 gross blood in the abdomen at the time of 13 her delivery. 14 To be more precise than that, 15 how much of a subcapsular bleed did she 16 have, her liver function tests were only 17 slightly abnormal when they were drawn at 18 1:45 in the morning. I don't know if you 19 could really gauge how much of a 20 subcapsular bleed she might or might not 21 have had at that point in time just using 22 the liver enzymes. But they were mildly 23 elevated, as opposed to being incredibly 24 elevated. Maybe there is some general 25 information we could get that way which 37 1 GIMOVSKY 2 would suggest she didn't have an 3 incredibly large hematoma at that time. 4 Q. If I understand what you are 5 suggesting as an underlying mechanism for 6 the bleed in the liver, you have mentioned 7 hypertension and coagulopathy as two 8 factors that you mentioned in association 9 with the bleed in the liver. Is it your 10 opinion that those are the factors that 11 caused the bleed in the liver? 12 A. Well, there could be other 13 factors that cause bleeding in the liver. 14 But in a case like this, the propensity 15 for coagulopathy and the nature of 16 hypertension within preeclampsia are the 17 two predisposing factors. 18 Q. They are also the two causative 19 factors that you are postulating here? 20 A. I think they are the 21 predisposing factors in this case. Where 22 the bleed occurred, they would be the 23 causative factors, yes. 24 Q. Can you tell me when this bleed 25 began? And obviously I'm not going to ask 38 1 GIMOVSKY 2 you to tell me what hour and what minute 3 after the hour. But to the best of your 4 ability with the use of ranges, can you 5 tell me when the bleed into the liver 6 parenchyma began? 7 A. That's a hard question to 8 answer. She had several hours of a severe 9 headache. And I don't really have a time 10 understanding of how long she was 11 generally not feeling well. Which I would 12 take to mean her nausea and the headache. 13 During the time frame in which 14 she had both the headache and the nausea, 15 it's speculative to try to figure out 16 exactly when it occurred. I don't know 17 how I could do that. I would say over 18 several hours would be my clinical 19 expectation. But I don't think I could do 20 any better than that. 21 Q. Okay. Let's try it another way 22 and see if we can -- I don't know, I 23 suppose, is as good an answer as I do 24 know, if that's in fact the case. But 25 let's try to explore it a little bit. 39 1 GIMOVSKY 2 Do you have an opinion that you 3 hold to a reasonable probability as to 4 whether the bleeding in the liver began 5 before Wanda was hospitalized? 6 A. I can't state to a degree of 7 medical certainty one way or the other. 8 Q. So it might have begun before, 9 it might have begun after? 10 A. Yes, sir. 11 Q. I presume you saw in the records 12 reference to shoulder complaints that 13 occurred at about 3:50 in the morning? 14 A. Yes, sir. 15 Q. Of what clinical significance 16 are those, if any, to you? 17 A. Well, they are listed in the 18 nursing notes as shoulder cramps. So they 19 could have just been shoulder cramps. 20 There is no way to know. 21 I think the conclusion drawn by 22 several others here was that the shoulder 23 cramps were the same as the complaint of 24 shoulder pain, which in this case could 25 represent subdiaphragmatic irritation 40 1 GIMOVSKY 2 between the liver and the diaphragm, 3 causing a reflex pain in the shoulder, 4 like we generally see with a ruptured 5 ectopic pregnancy. 6 There is no way to know if 7 that's what it meant. It could mean 8 that. There is not enough information in 9 there for me to be able to tell for sure 10 one way or the other. Certainly that's a 11 possibility. 12 Q. In retrospect, given what we 13 know about how this all unfolded -- 14 A. Well, in retrospect, I think 15 that we could make a reasonable argument 16 that that had to do with swelling of the 17 liver there or with the actual rupture, 18 which was also, if I remember correctly 19 from the general surgeon's note, at the 20 extreme side, left side of the liver. It 21 doesn't say if it was a right shoulder or 22 a left shoulder. And there is not much 23 description. But it would certainly be 24 consistent with that complaint if the 25 rupture had occurred at about that time. 41 1 GIMOVSKY 2 MR. HUMPHREY: Court reporter, 3 could you note my objection to that last 4 question. I wasn't able to get it in 5 before the doctor started to answer. 6 Q. Is the right shoulder or the 7 left shoulder of importance in making a 8 determination as to what the cause of the 9 complaints were? 10 A. No. But more of a description 11 of what was going on might be helpful if 12 we are trying to ascertain whether she had 13 a cramp from a muscle cramp or if she had 14 indeed an irritated diaphragm from 15 hemoperitoneum. 16 I think the pathognomonic 17 shoulder pain actually was left shoulder 18 pain. But I don't know for sure that I 19 could tell the difference based on which 20 shoulder it occurred in. 21 Q. So if I understand your 22 testimony correctly, given what we know 23 about how all this unfolded, you would 24 conclude that more likely than not the 25 shoulder pain was related to the liver? 42 1 GIMOVSKY 2 MR. HUMPHREY: Objection. 3 MR. PARKER: Objection. 4 A. I think what I said was it's 5 consistent. I don't know if that helps 6 you or doesn't help you. But it's 7 consistent with that diagnosis. And in 8 retrospect from what we learned, it 9 certainly could have been related to 10 that. But I don't have an opinion to a 11 degree of medical certainty that that's 12 related to that. 13 MR. PARKER: Move to strike. 14 Q. What you are suggesting is that 15 we don't have a documented description 16 that is sufficiently precise to give us 17 more information that might be helpful in 18 making this determination as to cause? 19 A. Well, I think that what we have 20 here is a very unusual complaint, shoulder 21 cramps, if indeed what the nurse meant was 22 it was shoulder pain or if that was crampy 23 or whatever. 24 Most of the time when you see 25 this complaint, the patient has an abdomen 43 1 GIMOVSKY 2 with blood in it due to a ruptured ectopic 3 pregnancy. And it's a pain, a very sharp 4 pain. It's not an infrequent finding. In 5 this context with a ruptured liver, it's 6 an unusual set of complaints. It may be 7 consistent or may not. I don't know. 8 Q. If you were a clinician seeing a 9 patient with HELLP syndrome, elevated 10 liver enzymes, reduced platelet count, and 11 a nurse observed a finding of shoulder 12 cramping, you sure as heck would want to 13 know about it, wouldn't you? 14 A. I would want to go and see the 15 patient and evaluate it myself. I would 16 certainly want to know about it, yes, sir. 17 Q. A significant finding? 18 A. Potentially. 19 Q. It's a potentially very 20 significant finding, correct? 21 A. Yes, it is. 22 Q. And what is your understanding 23 as to what was done with this information 24 regarding shoulder pain? 25 A. Well, according to Nurse Nuza, 44 1 GIMOVSKY 2 who was the midwife there, she didn't even 3 know that it occurred until afterwards. 4 So apparently nothing was done with the 5 information, in answer to your question. 6 Q. Can we agree that that 7 information was mishandled by the person 8 who observed it? 9 MR. HUMPHREY: Objection. 10 MR. PARKER: Objection. 11 A. I would agree with you. 12 Q. It should have been conveyed to 13 the nurse-midwife, at the very least? 14 A. Yes. That would have been 15 appropriate. 16 Q. And it is certainly information 17 that the obstetrician should have had 18 conveyed to him as well, either directly 19 or indirectly? 20 MR. HUMPHREY: Objection. 21 A. I think that given that the 22 nurse-midwife was there, she would have 23 then evaluated the patient. And had she 24 found it to be the type of shoulder pain 25 that might be important in a case like 45 1 GIMOVSKY 2 this, then the information should have 3 gone to Dr. Liu. 4 Q. Are you aware of the 5 disciplinary action that was taken against 6 the nurse in this case for failure to 7 convey that information? 8 MR. HUMPHREY: Objection. 9 MR. PARKER: Objection. 10 A. No, I'm not. 11 Q. Okay. We are at a bit of a 12 disadvantage here, because you don't have 13 what I have in front of me, which is a 14 document that I'm going to somehow try to 15 make visible to you. 16 A. There must be an electronic way 17 or a fax machine. 18 Q. We are working on it here. We 19 have got one of these visual presenters. 20 A. Okay. 21 Q. And whether we are going to be 22 able to make it -- give you this page, we 23 will see. 24 MR. PARKER: Toby, while you are 25 trying to make that work, I'm going to 46 1 GIMOVSKY 2 note my objection to your questioning him 3 about this. He has not reviewed the 4 document. It is not part of the basis of 5 his opinion. Thus your inquiry exceeds 6 the scope of inquiry permitted by the Ohio 7 rules of civil procedure. Hopefully I can 8 make the objection continuous so I don't 9 have to interrupt you. 10 MR. HIRSHMAN: Yes, you can do 11 that, Alan. 12 MR. HUMPHREY: Note my objection 13 as well. 14 I don't know if I'm going to be 15 able to use this. 16 MR. HIRSHMAN: I've introduced 17 it in other depositions before and marked 18 it. So I think we are probably safe if I 19 just describe it to you and get your sense 20 of things. 21 Q. It's been marked as an exhibit 22 to Dr. Sibai's deposition. And it was 23 marked as a exhibit to Dr. Ashmead's 24 deposition just this morning. And what it 25 is is a document that is called "Record of 47 1 GIMOVSKY 2 Warning or Disciplinary Action." And it 3 relates to Beverly Burton, who is the 4 nurse who was involved in Wanda's care 5 that morning. 6 And it indicates as a reason for 7 discipline unsatisfactory job 8 performance. And then it goes ahead and 9 indicates in fact five different issues 10 regarding her job performance, one of 11 which is the shoulder pain and what she 12 did with that information. And this 13 action states in that regard as follows: 14 At 3:50 patient complained of shoulder 15 cramp but no documentation of notifying 16 CNM or physician. And she was given an 17 opportunity to respond to that. And her 18 response is: Agree. 19 So I take it that you have no 20 dispute regarding the appropriateness of 21 disciplinary action in that regard 22 either? 23 MR. PARKER: Objection. Do you 24 have an opinion on that? 25 THE WITNESS: I have an 48 1 GIMOVSKY 2 opinion. 3 A. I agree. She should have 4 notified the nurse-midwife who was there 5 in labor and delivery. 6 Q. Then there is another one, it's 7 number 4. And it says -- have you looked 8 at the fetal monitoring strips? 9 A. Yes, sir. 10 Q. Okay. It says at 4:20 a.m., it 11 says 0420, fetal heart rate, and there is 12 an arrow going down to seventies with no 13 nursing interventions until 4:40 when CNM 14 was notified by another RN. 15 So what they are documenting in 16 this disciplinary action is a 20-minute 17 period where nothing was done for a fetal 18 heart rate that was certainly at least 19 nonreassuring. Do you agree with that 20 criticism? 21 A. Yes, I do. 22 MR. HUMPHREY: Objection. 23 Q. You have looked at these records 24 prior to this deposition? 25 A. The records of Wanda Wright from 49 1 GIMOVSKY 2 3/17 and 3/18, yes. 3 Q. You have those same criticisms 4 independent of this disciplinary action, I 5 presume? 6 MR. HUMPHREY: Objection. 7 MR. PARKER: Objection. 8 A. Criticism is a criticism. It 9 has nothing to do with the disciplinary 10 action. She should have notified the 11 midwife of the shoulder pain and there 12 should be documentation that steps were 13 taken for fetal distress. My opinion that 14 those were true has nothing to do with the 15 disciplinary action. 16 Q. In other words, you are not 17 parroting somebody else's opinions. In 18 fact, you didn't even know about them 19 before me telling you about them? 20 MR. PARKER: Objection. You can 21 answer it. 22 A. I didn't know about the 23 disciplinary action. 24 Q. Okay. Are you in a position to 25 support the quality of the care that was 50 1 GIMOVSKY 2 rendered by Dr. Liu in this case? 3 MR. PARKER: In all respects? 4 A. I'm not sure I understand the 5 question. Support it? 6 Q. Dr. Liu is the obstetrician who 7 was on call that night. Is that your 8 understanding? 9 A. I understand. My question was 10 whether support means make a comment on or 11 support it in a positive way. That's what 12 I didn't understand. 13 Q. Oh, okay. What I was asking you 14 is whether it is your position that 15 Dr. Liu's care and treatment in this case 16 comported with acceptable standards of 17 care. 18 A. That's not my opinion. 19 Q. In fact, it would be fair to say 20 that Dr. Liu failed to comport with 21 acceptable standards of care for multiple 22 reasons in this case? 23 A. It would be fair to say that 24 specifically when he got the second phone 25 call at 2:50 in the morning, he should 51 1 GIMOVSKY 2 have come into the hospital to see the 3 patient. And he failed to provide at the 4 standard of care in that regard. 5 Q. Okay. 6 A. It would be fair to say that by 7 counterdicting Nurse Nuza's order for mag 8 sulfate at 1:45 in the morning, that does 9 not comport with the standard of care. I 10 think those are the only two things I can 11 see off my notes that would meet that 12 definition. 13 Q. Let me ask you about one more, 14 then, and see what you think about it. 15 Did Dr. Liu ever order antihypertensive 16 medication? 17 A. No. 18 Q. For Wanda Wright? 19 A. No, sir. 20 Q. Should he have? 21 A. I think when a patient has a 22 diastolic blood pressure of more than 110, 23 the second number there, then the standard 24 of care calls for the patient to be 25 treated with antihypertensives. 52 1 GIMOVSKY 2 So at 2:10 in the morning when 3 her blood pressure was 217/112 and she had 4 four plus protein at that point in time, 5 he needed to know those blood pressures at 6 that point in time. And to have ordered 7 antihypertensives would be what the 8 standard of care would call for. 9 In addition, at that point in 10 time the blood pressure needed to be 11 repeated several times to see if indeed 12 that was one blood pressure or if the 13 blood pressures were going up or down or 14 what the series of blood pressures were. 15 So there were several things that needed 16 to be done at that time frame. 17 Q. Do you know whether Dr. Liu was 18 provided with information regarding the 19 diastolic rate going above 110? 20 A. It's my sense from Nurse Nuza's 21 deposition that he couldn't have known 22 that until the 2:50 phone call. 23 Q. Is it your understanding that he 24 was told that during that phone call? 25 A. From her description of what she 53 1 GIMOVSKY 2 told him, it would be my understanding 3 that he knew the blood pressure at that 4 point in time. 5 Q. And it was at that time that he 6 should have ordered antihypertensive 7 medication? 8 A. He should have had the blood 9 pressure repeated. And if the diastolic 10 blood pressure was 110 or greater, he 11 should have ordered apresoline or an 12 antihypertensive medication, yes. 13 Q. Had he done so, are we in 14 agreement that to a reasonable medical 15 probability, it would have reduced the 16 blood pressure as desired? 17 A. Well, we don't really know 18 that. She had very high blood pressure. 19 We don't know how much effect we would 20 have gotten from a test dose, which would 21 have been appropriate to have done in my 22 opinion. 23 So if she would have gotten a 24 test dose of 5 or 10 milligrams of 25 apresoline and her blood pressure 54 1 GIMOVSKY 2 rechecked in five or ten minutes, which is 3 the standard approach to this, I don't 4 know how much effect it would have had. 5 So I wouldn't be able to speculate what 6 the difference would be. But that would 7 have been the proper treatment. 8 Q. Are you in a position to say 9 that to a reasonable medical probability 10 her blood pressure would not have 11 responded to antihypertensive medication? 12 A. I don't think you can say 13 specifically. There are patients that 14 respond and patients who don't. Wanda 15 Wright was a 43-year-old woman. So she 16 may have had other issues with her 17 cardiovascular physiology. If she was a 18 12 year old or 16 year old, she might have 19 had a totally different set of responses. 20 So I don't know. 21 I would expect that her blood 22 pressure would have gone down. But how 23 much and how rapidly, I couldn't answer 24 because it would be speculative. 25 Q. I've read a little knowledge is 55 1 GIMOVSKY 2 dangerous. So what I say may not be 3 something you can in any fashion agree 4 with. But I'll try it anyway. 5 I have heard that 6 antihypertensive medication should be 7 given to women, hypertensive women in 8 pregnancy when their blood pressures -- 9 when their acutely elevated blood 10 pressures reach a mean arterial pressure 11 of 125 or greater. Is that another way of 12 looking at the issue of when 13 antihypertensive medication should be 14 administered? 15 MR. PARKER: I object to the 16 form of the question. 17 A. I think that I'm more familiar 18 with the standards that exist in several 19 editions of Williams, which says a 20 diastolic of 110. But I certainly would 21 understand that some mean arterial 22 pressure would correspond to that. I just 23 don't know if 125 is the number. 24 Certainly somebody who is 110 25 blood pressure in the third trimester, I 56 1 GIMOVSKY 2 teach people every day to give medication 3 for that. 4 Q. Okay. I want to talk to you 5 about some of the hospital employees and 6 what their obligations were when faced 7 with a physician who refuses to come in 8 and fails to give appropriate medication. 9 And I ask you these questions having had 10 an opportunity to look at other things, 11 frankly, that you have testified to in 12 other cases, including one here in town 13 not too long ago, the Parrish case in 14 particular. 15 So what I'm interested in asking 16 you is when it is that Nurse Nuza or Nurse 17 Burton had an obligation to implement the 18 chain of command to get this guy in and 19 doing what he was supposed to do. 20 MR. HUMPHREY: Objection. 21 MR. PARKER: I didn't hear a 22 question. I just heard an introduction to 23 a subject matter. Was there a question 24 posed? 25 MR. HIRSHMAN: I thought it was 57 1 GIMOVSKY 2 a question. But if you want to be 3 technical about it, I can see where you 4 might come to that conclusion too. 5 Q. Do you have an opinion as to 6 what the obligations were of Nurse Nuza 7 and Nurse Burton when confronted with a 8 situation where Dr. Liu did not come in 9 and did not prescribe necessary 10 medication? 11 A. Yes, I have an opinion. 12 MR. HUMPHREY: Objection. 13 Q. What is it? 14 A. I have an opinion. I think that 15 after the second phone call, Dr. Liu's not 16 coming into the hospital was something 17 that was intolerable and that Nurse Burton 18 and Nurse Nuza had an obligation to the 19 patient to advocate in another way for 20 her. One of the terminologies we use for 21 that is the chain of command. I 22 understand that. But I would say that it 23 was after the second phone call that that 24 point was reached, in my opinion. 25 Q. So that we are on the same page, 58 1 GIMOVSKY 2 that second phone call was the 2:50 phone 3 call that we have been discussing 4 previously? 5 A. Yes, it was. 6 Q. Correct? 7 A. Yes. 8 Q. And who should they have 9 contacted? 10 A. Depending on what the chain of 11 command was at St. Luke's Hospital, I 12 would expect the nursing supervisor and/or 13 the chairman of the department. And then 14 the loop is closed that way. 15 Q. If the chair of the department 16 is the culprit in question, where do you 17 go? 18 A. That's a good question. That's 19 a very good question. I don't know the 20 answer. I think you go to another 21 physician. Or you go to the chief medical 22 officer probably. 23 If you could get another 24 obstetrician who was there, you would have 25 some mechanism to deal with that. If 59 1 GIMOVSKY 2 there was no other obstetrician available 3 to you, then I think the appropriate 4 person is the chief medical officer to ask 5 what to do next. 6 Q. Do you see any evidence to 7 suggest that any of that was done in this 8 case? 9 A. No, I don't. 10 Q. And it's fair to say that by 11 failing to do that, they failed to provide 12 the patient advocacy functions that they 13 should have provided? 14 MR. HUMPHREY: Objection. 15 A. They failed to provide the 16 teamwork that's required to take care of 17 each patient, yes. 18 Q. Are you familiar with the 19 medical community in Cleveland in terms of 20 what hospitals exist here and where they 21 are located? 22 A. In general. 23 Q. Are you familiar with Metro 24 Health Medical Center as an institution in 25 town? 60 1 GIMOVSKY 2 A. Yes. 3 Q. And you are familiar with the 4 Rainbow Babies and Children's and, I guess 5 more relevant to our discussion here, the 6 McDonald House? 7 A. Yes. 8 Q. Part of University Hospitals? 9 A. Yes, I'm familiar with it. 10 Q. Those institutions would have 11 had well-equipped and well-staffed 12 obstetrical departments to deal with 13 patients like Wanda Wright, would they 14 not? 15 A. I would assume so. 16 Q. Can you think of any reason why 17 a transfer to one of those institutions 18 should not have been implemented? 19 MR. HUMPHREY: Objection. 20 MR. PARKER: Objection. 21 A. Well, Dr. Liu in his testimony 22 said they took care of patients like this 23 at St. Luke's. So if that was what they 24 normally did, I certainly don't have a 25 reason to speculate that they should have 61 1 GIMOVSKY 2 transferred her. 3 And then the other issue is 4 assuming that the blood pressures we have 5 are an accurate reflection of what her 6 blood pressure was, and unfortunately we 7 only have those four blood pressures, it 8 might be an unnecessary risk to transfer 9 the patient. I don't know how far away 10 they are actually at that time of night. 11 But one way or the other, I 12 can't say for sure, either she -- I think 13 she was so ill she needed to be treated 14 and not triaged out. And based on what 15 Dr. Liu said, they treated people with 16 HELLP syndrome. So I don't have any 17 reason to suspect that. 18 Had she been premature in 19 addition, then I would think they would 20 have made more of an effort to transfer 21 her to the neonatal aspect. 22 Q. So rather than have her 23 transferred, the right thing to have 24 happen here is for her to be treated with 25 a doctor who had enough concern to come in 62 1 GIMOVSKY 2 and see the woman? 3 MR. PARKER: Objection. 4 A. If Dr. Liu had wanted 5 consultation, he could have just called 6 over to McDonald House. I'm sure there 7 was a perinatologist who was on call and 8 he could have gotten whatever other 9 telephone advice he needed about the 10 medications. I don't think there would 11 have been any advantage for a patient at 12 37 weeks with those blood pressures in 13 transferring her. 14 If I was called with that set of 15 scenarios as a receiving doctor, I would 16 say to give her some medication and 17 deliver her. And if things don't pan out 18 so that that's easy to do, then you can 19 send her over. But it looks like she has 20 a problem that's acute enough to keep her 21 at the hospital. 22 Q. If you had gotten that call from 23 Dr. Liu and he had told you that he has a 24 woman 42 years of age, 37 weeks gestation, 25 13 prior deliveries, severely preeclamptic 63 1 GIMOVSKY 2 with documented HELLP syndrome and with 3 evidence of shoulder cramps or pain, what 4 would you have told him to do in terms of 5 treatment? 6 MR. HUMPHREY: Objection. 7 MR. PARKER: Objection. 8 A. Well, I would have to ask him if 9 he thought that her shoulder pain 10 represented hemoperitoneum, what the rest 11 of her blood pressures and lab studies 12 were, and whether or not he felt she was 13 so acute she needed to be delivered 14 imminently. It's hard to tell from the 15 hypothetical or -- yes, I guess 16 hypothetical question you just asked me. 17 My advice would be to go back 18 and evaluate the patient to see if she 19 needed acute delivery by Cesarean section 20 perhaps or whether or not rupturing her 21 membranes and giving her Pitocin might 22 solve the problem. 23 Probably the other thing that I 24 would say at 3:50 in the morning, assuming 25 that's when I was called with this, would 64 1 GIMOVSKY 2 be to get another platelet count to see 3 what her platelets were, because that 4 would affect the route of delivery I might 5 recommend in this case. 6 Q. And if he told you that he 7 couldn't determine whether the shoulder 8 pain was hemoperitoneum related or not but 9 he certainly was concerned about it, and 10 if he told you that the platelet counts on 11 a repeat platelet count were going down, 12 what would you have told him to do? 13 MR. PARKER: Objection. 14 A. I think I would have recommended 15 that they get platelets available for 16 transfusion. And that they proceed -- if 17 her cervix was uninducible and they 18 couldn't rupture her membranes, she needed 19 delivery because of the suspicion that you 20 have to have that she had some kind of 21 hepatic involvement. 22 Q. Meaning delivery by C-section? 23 A. Yes, sir. 24 Q. Now, you have looked at these 25 records. She's got a cervix that's noted 65 1 GIMOVSKY 2 to be closed, I believe, correct? 3 A. She was noted to be closed and 4 60 percent effaced, yes. 5 Q. And at minus two station is it? 6 A. It certainly wasn't engaged. I 7 don't know which station. I don't have it 8 written down here. 9 Q. Given that set of circumstances 10 regarding her cervix and engagement, if 11 you had been told that, how would that 12 lead you to advise Dr. Liu as it relates 13 to C-section versus inducement? 14 MR. PARKER: Objection. 15 A. I think -- it depends on what 16 time you are talking about. 3:50 in the 17 morning when the shoulder cramps 18 occurred? 19 Q. Right. 20 A. Well, if he did a stat repeat 21 platelet count and her platelet count was 22 substantially lower than the 93,000, I 23 would suggest to get a platelet 24 transfusion and I would deliver the 25 patient by Cesarean section. 66 1 GIMOVSKY 2 Q. Would you advise him to have 3 other blood products made available 4 immediately as well? 5 A. Sure. I would have presumed he 6 would have already done that. Fresh 7 frozen plasma and packed red cells, yes. 8 Q. And would you have also advised 9 him to bring in a surgical consult at that 10 time? 11 A. No. 12 Q. Given the fetal monitoring strip 13 that you have in front of you, I guess I'm 14 asking you to shift gears. We have been 15 focusing on the maternal picture. I'm 16 going to ask you to focus on the fetal 17 picture and ask you based on what you see 18 in terms of the fetal picture on the fetal 19 monitoring strip, when is it that you, if 20 you had been present, would have delivered 21 this child by C-section? 22 MR. PARKER: Objection. 23 (Witness reviews documents.) 24 A. I think you could make the 25 decision to do it. I think I would have 67 1 GIMOVSKY 2 made the decision to deliver her by 3 C-section at 4:30 and then would have 4 moved to rapidly get this baby delivered. 5 Q. How long at your institution 6 would it take to deliver the baby if you 7 decided to do it at 4:30? 8 A. For fetal indication like this, 9 I would say probably 15 minutes. Ten or 10 15 minutes. It depends where everybody 11 is. 12 Q. So you would have had this baby 13 out by 4:45? 14 A. I would certainly expect to, 15 yes. 16 Q. And given the circumstances 17 surrounding the HELLP syndrome and the 18 complaints of shoulder pain, you 19 presumably would have made efforts to 20 evaluate the status of the liver at that 21 time? 22 A. Absolutely. 23 Q. Intraoperatively? 24 A. Yes, sir. 25 Q. And if the liver was not yet 68 1 GIMOVSKY 2 ruptured, what would you have done? 3 A. Closed the patient up quickly 4 and replaced the blood and treated her as 5 her chemistries indicated. 6 Q. And if the liver was found to be 7 ruptured, I presume you would have called 8 a surgical consult or would you have done 9 the remaining surgery yourself? 10 A. At my hospital I would have 11 called -- we probably have a fellow in our 12 hospital at five o'clock in the morning. 13 But I would have called for the chief 14 surgical resident to come by and whoever 15 was the surgery attending and/or the 16 fellow. I would have gotten more help. 17 Q. It would have been your 18 expectation that the surgical approach to 19 the liver, if it were in fact ruptured, 20 would be to pack it and drain it? 21 A. Yes, sir. That's my 22 understanding of what is done. 23 Q. Do you have any criticism of 24 Dr. Gyves? 25 A. My understanding was Dr. Gyves 69 1 GIMOVSKY 2 was called at the very end, because he 3 lives closer to the hospital. So I have 4 no criticism of Dr. Gyves. 5 Q. Do you have any criticism of any 6 of the surgeons who were involved in 7 Wanda's care subsequent to the C-section? 8 A. I wouldn't be in a position to 9 criticize them. But I don't have any 10 criticism of them. 11 Q. Okay. Do you feel that Wanda 12 did anything to cause this set of 13 circumstances to fall upon her? 14 A. No, I don't. 15 Q. So you are familiar with the 16 term "contributory negligence"? 17 A. Yes, I am. 18 Q. Do you think she was 19 contributorily negligent in any fashion in 20 this case? 21 A. Not to my understanding of 22 having looked at her prenatal records and 23 such. She appeared to be an average 24 patient. 25 Q. Do you remember the discussion 70 1 GIMOVSKY 2 we had a few moments ago about what you 3 would do if you were called by Dr. Liu and 4 asked for your advice over the phone? 5 A. Yes. 6 Q. Would you have made any 7 recommendations to him about imaging 8 studies? 9 MR. PARKER: Objection. You can 10 answer. 11 A. No. No, there are no indicated 12 imaging studies for the complaint, not in 13 the clinical evaluation and the normal 14 course of the disease. 15 Q. I may have asked you this in 16 some way. I know we have discussed it, 17 but I'm not sure we discussed this precise 18 issue precisely this way. At the time of 19 the delivery, there was a rupture which 20 was found at the liver. That's your 21 understanding, I believe? 22 A. That's what is in the notes, 23 yes. 24 Q. Do you have an opinion as to 25 when that rupture occurred? Now we are 71 1 GIMOVSKY 2 talking rupture rather than bleed. So I 3 think that we are talking about something 4 different than we were talking about 5 before? 6 A. Yes, I have an opinion. 7 Q. Okay. 8 A. And my opinion is that the only 9 information that exists that's germane to 10 that question is the shoulder cramps she 11 had at 3:50. Whether or not that more 12 likely than not goes with that opinion, 13 it's consistent. I think that's what I 14 tried to say before. 15 It's certainly consistent with 16 it. But whether or not that was the 17 actual moment when that occurred, I don't 18 know. I don't know the answer to the 19 question. 20 She had a very large hematoma, 21 according to the notes, the operative 22 report. It would take a certain amount of 23 pressure to rupture the liver. And she 24 had a massive hemoperitoneum. I don't 25 know how I could possibly know. 72 1 GIMOVSKY 2 If she had had hypotension 3 during her labor and delivery, suppose her 4 blood pressure had all of a sudden 5 dropped, then we could presume she had a 6 hemmorhage from the rupturing of the 7 liver. That might be consistent with it 8 one way or another. But that's not what I 9 noted here. There is not enough blood 10 pressure to be able to make a shift in 11 vital signs out of that argument. The 12 only thing we have here are the shoulder 13 cramps. It's not my opinion that it's 14 more likely than not that that's 15 indicative of that, only that it's 16 consistent. 17 Q. Should there have been more 18 blood pressures taken? 19 A. I believe in this case, yes. 20 Q. Whose obligation was that? 21 MR. HUMPHREY: Objection. 22 A. Everybody on the team has the 23 shared obligation to take care of the 24 patient. And that includes Nurse Burton, 25 Nurse Nuza, and Dr. Liu. So I don't think 73 1 GIMOVSKY 2 any one of them has the obligation. I 3 think all three of them have the 4 obligation. 5 Q. This fetal bradycardia was 6 caused by -- do you have an opinion as to 7 what caused it? 8 A. The bradycardia -- yes, I have 9 an opinion. And I think the opinion that 10 I would give you -- I assume you want my 11 opinion. 12 Q. I do. 13 A. The bradycardia was related to 14 the cervidil that was placed, because the 15 cervidil caused the uterus to contract. 16 And the contractions of the uterus is what 17 precipitated the bradycardia. That's not 18 an uncommon event in a patient who has 19 severe pregnancy-induced hypertension. 20 Those contractions will throw the baby 21 over the edge. So I think that's what 22 lead to the bradycardia, the cervidil. 23 Q. So you are not of the opinion 24 that the fetal bradycardia was caused by a 25 loss of -- was caused by a circulatory 74 1 GIMOVSKY 2 collapse of the mother? 3 A. Again, it could be. It could 4 have been related to an acute bleeding and 5 ischemia and hypovolemia, that argument. 6 But what I do know is that it's related to 7 the cervidil being placed and the uterine 8 activity on the monitor. So I think that 9 is probably my second choice as to the 10 cause. My primary guess would be that 11 it's due to the contractions of the uterus 12 in a woman who is acutely hypertensive. I 13 think it's consistent. I just can't make 14 that the first choice. 15 Q. All right. Are those the only 16 two choices, in your mind? 17 A. There wasn't anything else in 18 here that I could see that would cause 19 that kind of change. Magnesium sulfate 20 shouldn't have caused that. I don't see 21 anything else that comes to light here to 22 give me a reason for bradycardia. Other 23 than I think the cervidil did. 24 But certainly it's possible that 25 there is hypovolemia. The problem, 75 1 GIMOVSKY 2 though, is that there is not any real 3 reason why the fetus would be 4 hypovolemic. The mother is bleeding. And 5 that's a separate problem. 6 If the patient had had an 7 abrupted placenta, a separation of the 8 placenta in addition to that, then maybe 9 that argument. 10 I think there are secondary 11 changes that occur in the fetal 12 circulation as a result of contractions. 13 So to some extent the decelerations 14 reflect hypovolemia. But primarily it's 15 due to the uterine contractions. 16 Q. So there are two potential 17 etiologies, one of which you think is more 18 likely than the other. The one that you 19 think is the most likely of the two is the 20 cervidil causing excessive contractibility 21 of the uterus? 22 A. Yes. The cervidil would have 23 caused the uterus to contract a little 24 bit. That's how it helps to ripen the 25 cervix. I think in this case that was 76 1 GIMOVSKY 2 enough to throw the baby over the edge. 3 I can't exclude the fact that 4 the mother had cardiovascular collapse. 5 But there is nothing in the nursing notes 6 to suggest that she lost consciousness and 7 had a shift in her vital signs. 8 If you will look at five o'clock 9 in the morning, it says the patient went 10 limp and was taken to the OR. That 11 certainly is more consistent with the 12 dramatic shift from a rupturing liver than 13 shoulder cramps. 14 Her blood pressure at four 15 o'clock in the morning was still 206/111. 16 So I don't think that -- that doesn't go 17 with the shoulder cramps and that being 18 responsible timing-wise to go with the 19 rupture. Certainly at 5:01 in the morning 20 when the patient goes limp, maybe that 21 goes with it. 22 Certainly the patient was a 23 setup for these things to happen and had 24 the massive hematoma. But I still think 25 it was the cervidil that put the fetus 77 1 GIMOVSKY 2 over the edge. 3 Would it be okay if I took a 4 break for a second? 5 Q. Absolutely. 6 (Recess: 4:56 to 5:00 p.m.) 7 Q. Dr. Gimovsky, do you have some 8 notes that you made in regard to this 9 case? 10 A. Yes, sir, I do. 11 Q. Can you tell me how many pages 12 you have there? 13 A. I have two pages, which is 14 essentially a time line of what occurred 15 to Ms. Wright. 16 Q. Is there writing on the front 17 and back? 18 A. Just the front. 19 MR. PARKER: It's typewritten. 20 MR. HIRSHMAN: Pardon me? 21 MR. PARKER: I was going to say 22 it's typewritten. You were talking about 23 writing on front and back. 24 MR. HIRSHMAN: It's typed. 25 Q. I'd like you to provide Alan 78 1 GIMOVSKY 2 with a copy of those when he leaves 3 today. 4 MR. HIRSHMAN: Alan, if you 5 would be so kind as to send them to me, I 6 would appreciate it. 7 MR. PARKER: I'll take that 8 under advisement. I suspect we will do 9 just that. But I'll make sure that I have 10 a copy and that I segregate it so that Les 11 can take a position on them. 12 MR. HIRSHMAN: Okay. I guess I 13 can't ask for more, or I would. But you 14 are there and I'm here and I can't grab 15 you. 16 MR. HIRSHMAN: Around the neck. 17 THE WITNESS: I knew there was 18 an advantage to this. Two points for that 19 one. 20 MR. PARKER: Off the record. 21 (Discussion off the record.) 22 (Deposition Exhibit 1 marked for 23 identification.) 24 Q. Are you familiar with the 25 current mortality rates associated with 79 1 GIMOVSKY 2 HELLP syndrome? 3 A. I don't know what you mean by 4 current. 5 Q. Well, those that have been 6 tabulated within the last let's say 7 decade, those that are associated with 8 current methods of treatment. 9 A. You mean all comers with HELLP 10 syndrome or HELLP syndrome with liver 11 bleeds? 12 Q. I'm going to start there. We 13 are going to narrow it down. 14 A. I don't know the answer to your 15 question either way. It would be my sense 16 that very few people die from HELLP 17 syndrome, whereas it would be my sense 18 also that many of the women unfortunate 19 enough to have subcapsular bleeding with 20 rupture of the liver do die. But I don't 21 know the specific numbers. 22 I know the older numbers for 23 hepatic rupture were about two-thirds of 24 the women who had hepatic rupture died. I 25 could find the reference for that. But I 80 1 GIMOVSKY 2 don't know what the current numbers that 3 you are seeking are. 4 Q. We can agree that the older 5 literature looks pretty dismal in that 6 regard? 7 A. Yes, it did. 8 Q. Whether the more current 9 literature shows a different mortality 10 rate, you are not in a position to say is 11 what I hear you saying. 12 A. I would assume it's better for 13 HELLP syndrome. But HELLP syndrome is 14 only 15 years old as a diagnosis in and of 15 itself. And most of the liver rupture 16 data is before the HELLP syndrome was 17 defined. So I don't know how you would 18 make that comparison. 19 HELLP syndrome wasn't even 20 defined until Weinstein defined it in the 21 early eighties. So there isn't old data 22 from that. There is only newer data from 23 that. Liver rupture, catastrophic liver 24 rupture, the series that I just mentioned, 25 is before that time frame. We don't see 81 1 GIMOVSKY 2 very many of those. So I'm not sure how 3 meaningful the comparison would be. 4 I can tell you that I expect 5 that very few people die from HELLP 6 syndrome. So it's got to be an unusual 7 occurrence, although it can have very 8 severe consequences and it's a management 9 problem. But most of the patients that 10 I've seen in the past ten years with HELLP 11 syndrome have lived and done okay, as far 12 as I can tell. 13 Q. Let's talk about HELLP syndrome 14 associated with hepatic rupture. Are you 15 able to give me figures as to the 16 mortality rate? 17 A. No. I would defer to 18 Dr. Sibai. I think he is the only one 19 with enough experience to be able to make 20 that comment. 21 Q. I'm looking at your report 22 here. And in the last paragraph, you 23 write, "Mrs. Wright was critically ill at 24 the time of her admission to St. Luke's 25 hospital." You still agree with that 82 1 GIMOVSKY 2 position? 3 A. Yes, I do. 4 Q. You go on to say, "Regardless of 5 the medical care provided by Dr. Liu and 6 Columbia/HCA, it is my opinion to a degree 7 of medical certainty that the tragedy that 8 befell her was unavoidable." 9 What do you base that opinion 10 on? 11 A. The descriptions that the 12 surgeons made of her liver and the 13 description that either Dr. Liu or 14 Dr. Gyves made of her extensive hepatic 15 hematoma. 16 Q. What is it about the description 17 that you were relying on? 18 A. The fact that they described it 19 as a large hematoma and had to pack it 20 twice just to stem the bleeding. That's 21 what I have based it on. 22 I mean a ruptured capsule of the 23 liver is a very serious problem. Having 24 liver failure on that basis afterwards is 25 a significant risk and something that 83 1 GIMOVSKY 2 happens to some of these patients. There 3 isn't a lot of experience that I know of 4 anybody in OB/GYN has had with ruptured 5 livers. But based on the older experience 6 that does exist, we still don't have any 7 way to stop the bleeding. This patient 8 had to be packed twice. And so that's the 9 impression that I get from reading the 10 records. 11 Q. Had she been taken to surgery 12 earlier, are you in a position to render 13 an opinion as to whether or not it would 14 have changed her prognosis? 15 A. Yes, I am in a position and I 16 have an opinion. I think depending on 17 what time she would have been taken to 18 surgery -- I'm sorry. Let me rephrase 19 that. 20 My opinion is that any time 21 after she was admitted to the hospital was 22 too late to have made any difference. 23 That's why I wrote that paragraph the way 24 I did. 25 Q. And what is the basis of you 84 1 GIMOVSKY 2 saying that? 3 A. Just based upon the natural 4 history of a ruptured subcapsular bleed of 5 the liver, from what I've read and what 6 I've heard from other people, my 7 experience with patients who are ill. 8 Q. So would it be fair to say that 9 your opinions in that regard are based on 10 that literature that we previously 11 discussed? 12 A. It's based on that literature 13 and it's based upon the case-by-case 14 anecdotal experience that's available 15 among the community of perinatologists. 16 It's clear that at some point in 17 time she would have had not a rupture. 18 She would have just had a subcapsular 19 hematoma. Had she only had that at the 20 time of surgery, then I think we could 21 make the conclusion that the outcome would 22 have been different. 23 But I don't think in this case 24 we have enough -- I don't have enough 25 information to be able to say that this is 85 1 GIMOVSKY 2 a calamity that would have been avoided 3 had the strict standard of care been 4 applied to. And I think that's what 5 Mr. Spisak asked me in this case. 6 Q. We have already established that 7 you don't know when this ruptured, 8 correct? 9 A. Yes, sir. 10 Q. When you talk about literature 11 dealing with the natural history, other 12 than the literature that you described 13 before that suggested, and I think which 14 you indicated was old literature, which 15 suggested that two-thirds of patients with 16 hepatic rupture die, are you able to point 17 me to any other literature? 18 MR. HUMPHREY: Objection. 19 A. I haven't done a 20 literature-specific search for this case. 21 But the subject comes up from time to 22 time. So it's my sense that that is what 23 I would find if I looked at the last ten 24 or 15 years of literature. I haven't 25 looked specifically. 86 1 GIMOVSKY 2 Q. So if the more modern literature 3 gives more optimistic statistics for 4 survival with hepatic rupture, you would 5 be forced to reconsider your opinion? 6 MR. PARKER: Objection. 7 MR. HUMPHREY: Objection. 8 MR. PARKER: You are really into 9 speculation. 10 A. I think that if there was a 11 series of hepatic rupture under the 12 circumstances of severe preeclampsia and 13 HELLP syndrome, that would be true. There 14 probably is some modern literature on 15 traumatic rupture of the liver and 16 lacerations that are sustained that way. 17 But it's really not the same set of 18 circumstances as a woman who is 37 weeks 19 pregnant and preeclamptic. 20 So if there was a series like 21 that, I would certainly want to know 22 that. I don't believe there is in terms 23 of liver rupture. I don't think the 24 general surgeon literature on ruptured 25 liver would answer the question, if I 87 1 GIMOVSKY 2 understand what you are saying. 3 Q. So let me try to be fair and 4 precise about this. If you were to be 5 presented with modern literature dealing 6 with hepatic rupture in HELLP syndrome 7 patients showing a significantly more 8 optimistic likelihood of survival than 9 what you have suggested based on the old 10 literature, you would have to seriously 11 consider revising your opinions? 12 MR. HUMPHREY: Objection. 13 MR. PARKER: Objection. 14 A. I would certainly read the 15 literature very carefully. If I thought 16 it called for that, I would. 17 Q. Now, the anecdotal experience 18 that you talked about is clearly not 19 yours, because we have already discussed 20 what your experience is with hepatic 21 rupture and you have never seen such a 22 case? 23 A. That's true. 24 Q. Correct? 25 A. Yes, sir. 88 1 GIMOVSKY 2 Q. Is there any other anecdotal 3 literature or anecdotal experience that 4 you presently are aware of which you bring 5 to bear on this question? 6 A. Not specifically. 7 Q. I'm about done here. In fact, I 8 am. Thank you for your patience. My 9 truck is no better than the cars in front 10 of me. I apologize for that. Probably 11 the best thing to do -- I do have one more 12 question. 13 Have you contemplated -- in your 14 report you talk about the long-term 15 complications that were sustained by 16 Wanda, I believe. Second to last 17 paragraph. And ultimately she succumbed 18 to long-term complications of severe 19 preeclampsia. 20 Were you made aware of the fact 21 that Wanda has now died? 22 A. Yes. She had an -- 23 Q. Go ahead. 24 A. That's okay. I'll wait. 25 Q. Do you have an opinion as to 89 1 GIMOVSKY 2 whether her death was proximately caused 3 by the injuries that she sustained on 4 March 17, 1998 during her labor and 5 delivery? 6 MR. HUMPHREY: Objection. 7 A. If by injuries you mean her 8 ruptured liver capsule. Is that what you 9 are specifically referring to? 10 Q. Presumably we can agree to this 11 much. During that period of time, she did 12 rupture her liver capsule. She did 13 sustain neurologic injuries of a 14 devastating nature. And she remained in a 15 neurological compromised state from then 16 on, correct? 17 A. Yes. 18 Q. My question is simply this. She 19 then died? 20 A. Yes, sir. 21 Q. She recently died at the end of 22 June, the beginning of July. Do you have 23 an opinion as to whether her death was 24 caused by the injuries she sustained on 25 March 17, 1998? 90 1 GIMOVSKY 2 A. Yes, I do. 3 Q. And what is your opinion? 4 A. That she did die as a result of 5 the complications she suffered on the 6 17th. 7 MR. HIRSHMAN: I have no further 8 questions. I thank you for your time. 9 THE WITNESS: My pleasure. 10 MR. HIRSHMAN: Probably the best 11 way for you to do this is to send your 12 bill to me via Alan or Les Spisak and I 13 will see that it's paid. 14 THE WITNESS: Thank you. 15 MR. PARKER: Thanks. 16 MR. HUMPHREY: I don't have any 17 questions. 18 Let's go back on the record. 19 BY MR. HIRSHMAN: 20 Q. I've been told that I did not 21 ask you for that last opinion to a 22 reasonable medical probability, that 23 opinion being the opinion that causally 24 relates the event of the 17th of March to 25 Wanda's death. Do you hold those opinions 91 1 GIMOVSKY 2 to a reasonable medical probability? 3 A. Yes, I do. 4 MR. HIRSHMAN: Thank you. 5 (Time noted: 5:20 p.m.) 6 7 8 9 10 __________________________ 11 MARTIN L. GIMOVSKY, M.D. 12 13 Subscribed and sworn to before me 14 this day of , 2000. 15 16 _________________________________. 17 18 19 20 21 22 23 24 25 92 1 2 C E R T I F I C A T I O N 3 4 5 6 I, JOSEPH RAVENELL, a Court Reporter 7 and a Notary Public, do hereby certify 8 that the foregoing witness, MARTIN L. 9 GIMOVSKY, M.D., was duly sworn on the date 10 indicated, and that the foregoing is a 11 true and accurate transcription of my 12 stenographic notes. 13 I further certify that I am not 14 employed by nor related to any party to 15 this action. 16 17 18 19 20 21 _________________________ 22 JOSEPH RAVENELL 23 24 25 93 1 2 E X H I B I T S 3 4 DEPOSITION 5 EXHIBIT DESCRIPTION PAGE 6 1 Dr. Gimovsky's notes, 78 7 consisting of two 8 typewritten pages 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 94 1 2 LITIGATION SUPPORT INDEX 3 4 5 DIRECTION TO WITNESS NOT TO ANSWER 6 Page Line Page Line 7 8 (None) 9 10 11 REQUEST FOR PRODUCTION OF DOCUMENTS 12 Page Line Page Line 13 78 4 14 15 16 17 INFORMATION TO BE FURNISHED 18 Page Line Page Line 19 20 (None) 21 22 23 24 25