0001
 1   The State of Ohio,  )
 2   County of Cuyahoga. )  SS:
 3            IN THE COURT OF COMMON PLEAS
 4   Mary Williams, etc.,     )
 5                            )
 6            Plaintiff,      )Case No.
 7            -vs-            )406184
 8   Parma Community General  )
 9   Hospital, et al.,        )
10            Defendants.     )
11                  - - - o0o - - -
12       Deposition of WILLIAM HAHN, JR., M.D., a
13   Defendant herein, called by the Plaintiff as
14   if upon cross-examination under the statute,
15   and taken before Luanne Stone, a Notary
16   Public within and for the State of Ohio,
17   pursuant to the agreement of counsel, and
18   pursuant to the further stipulations of
19   counsel herein contained, on Wednesday, the
20   6th day of December, 2000 at 4:00 o'clock
21   P.M. at the offices of Nurenberg, Plevin,
22   Heller & McCarthy, the Standard Building,
23   the City of Cleveland, the County of
24   Cuyahoga and the State of Ohio.
25   
0002
 1   APPEARANCES:
 2   
 3             On behalf of the Plaintiff:
 4             Nurenberg, Plevin, Heller &
 5             McCarthy, by:
 6             Harlan Gordon, Esq.
 7             David Paris, Esq.
 8   
 9   
10             On behalf of the Defendants,:
11             Dr. William Hahn and The
12             Women & Wellness Center, by:
13             Bonezzi, Switzer, Murphy &
14             Polito, LLP., by:
15             William Bonezzi, Esq.
16   
17             On behalf of the Defendants,
18             Dr. Hsieh and
19             Physician Staffing:
20             Hanna, Campbell & Powell, by:
21             Jeffrey E. Schobert, Esq.
22   
23   
24   
25   
0003
 1   APPEARANCES:
 2             On behalf of the Defendant:
 3             Parma Community General Hospital:
 4             Weston, Hurd, Fallon, Paisley &
 5             Howley, by:
 6             John Jeffers, Esq.
 7   
 8                 - - - O0O - - -
 9   
10   
11   
12   
13   
14   
15   
16   
17   
18   
19   
20   
21   
22   
23   
24   
25   
0004
 1               INDEX OF OBJECTIONS
 2   PAGE/LINE           PAGE/LINE
 3   BY MR. JEFFERS      BY MR. BONEZZI
 4   14/20               81/16
 5   BY MR. BONEZZI      BY MR. SCHOBERT
 6   15/9                83/8
 7   BY MR. JEFFERS      BY MR. BONEZZI
 8   17/22               83/25
 9   BY MR. BONEZZI      BY MR. SCHOBERT
10   26/7                84/1
11   BY MR. SCHOBERT     BY MR. BONEZZI
12   26/9                89/24
13   BY MR. BONEZZI      91/8
14   27/9                91/25
15   30/19               96/11
16   35/2                107/23
17   BY MR. JEFFERS      109/16
18   40/8                111/6
19   BY MR. BONEZZI      118/9
20   40/9                118/12
21   66/10               120/8
22   67/8                124/14
23   76/15               126/15
24   79/14               128/12
25   80/6                131/18
0005
 1               INDEX OF OBJECTIONS
 2   PAGE/LINE           PAGE/LINE
 3   BY MR. SCHOBERT     BY MR. SCHOBERT
 4   132/18              156/1
 5   BY MR. BONEZZI      BY MR. JEFFERS
 6   132/25              158/7
 7   133/7               BY MR. BONEZZI
 8   BY MR. SCHOBERT     160/15
 9   136/12              BY MR. SCHOBERT
10   BY MR. BONEZZI      160/17
11   142/3
12   BY MR. JEFFERS
13   142/4
14   BY MR. BONEZZI
15   142/14
16   BY MR. JEFFERS
17   142/15
18   BY MR. BONEZZI
19   144/3
20   145/3
21   146/20
22   147/9
23   155/24
24                 - - - O0O - - -
25   
0006
 1               P R O C E E D I N G S
 2         WILLIAM HAHN, JR., M.D., being of
 3   lawful age, having been first duly sworn
 4   according to law, deposes and says as
 5   follows:
 6   CROSS-EXAMINATION OF WILLIAM HAHN, JR., M.D.
 7             MR. BONEZZI:   Doctor, you're
 8   going to have to also speak up to make sure
 9   that everybody hears.
10             THE WITNESS:   Okay.
11   BY MR. GORDON:
12   Q    Dr. Hahn, am I pronouncing your name
13   directly?
14   A    Uh-huh.
15   Q    My name is Harley Gordon, and I'm one
16   of the attorneys representing the estate of
17   Mary Williams.  Mr. Paris, my partner, will
18   be here, I hope, in the near future, and
19   he'll also -- he also represents the estate
20   of Mary Williams.
21             This afternoon and into this
22   evening, I will be asking you some questions
23   primarily regarding your involvement in the
24   care and treatment of Mary Williams at Parma
25   Community General Hospital in June of 1999.
0007
 1             MR. BONEZZI:   Harley, before we
 2   go into all of your questions, you are aware
 3   that Judge Saffold granted your motion to
 4   compel.  Is it Saffold in this case?  There
 5   was a motion to compel relative to Dr.
 6   Hahn's deposition being taken prior to
 7   December 8th, and I was informed of that
 8   this -- this morning, and for the record,
 9   what I would request is that, given the fact
10   that we were able to commence this
11   deposition prior to the time that you
12   needed, that you so inform the court.
13   Otherwise, we're going to be in front of the
14   court relative to that motion to compel, and
15   anything else that you're going to be
16   requesting.  Plus, I would like to also put
17   on the record that I have informed you that
18   we can only go until 7:00 this evening, and
19   we will have to reconvene Dr. Hahn's
20   deposition at a later time mutually
21   convenient for yourself, David, myself and
22   Dr. Hahn and the rest of the parties.  And,
23   I apologize for interrupting.  Go ahead.
24   BY MR. GORDON:
25   Q    As I was discussing with you, Dr. Hahn,
0008
 1   I'll be asking you questions regarding your
 2   involvement in the care and treatment of
 3   Mary Williams, primarily at Parma Community
 4   General Hospital in June of 1999.  During
 5   the course of my questioning, please make
 6   sure you understand the question before you
 7   answer it.  Do you understand that, sir?
 8   A    Uh-huh, yes.
 9   Q    I'm sure Mr. Bonezzi has probably gone
10   over these instructions or guidelines, but I
11   want to emphasize them.  So, make sure you
12   understand the question.  If you don't
13   understand the question, please don't answer
14   it and tell me to rephrase it or define the
15   term.  Do you understand that, sir?
16   A    Yes, uh-huh.
17   Q    The reason being because we're relying
18   on the fact -- fact that you understood the
19   question and answered it --
20   A    Uh-huh.
21   Q    -- as best as possible.  Do you
22   understand that, sir?
23   A    Yes.
24   Q    You also have to answer your questions
25   verbally, okay?
0009
 1   A    I'm sorry?
 2   Q    Out loud.
 3   A    Okay.
 4   Q    No hmms or --
 5   A    Uh-huh.
 6   Q    Okay?
 7   A    Yes.
 8   Q    So the court reporter can take down
 9   your testimony.  One other thing, if you
10   want to take a break for whatever reason, I
11   don't know if you have a pager with you or
12   for any other reason, just stop me --
13   A    Okay.
14   Q    -- and we'll take a break.  Do you
15   understand that?
16   A    Yes.
17   Q    Okay.  First thing I'd like to go is
18   into your background.
19   A    Okay.
20   Q    We'll begin at the beginning.  Could
21   you give us your full name and home address?
22   A    Sure.  It's William Kenneth Hahn,
23   Junior, M.D. as per the top of the CV, and
24   my home address is 2515 Brook Haven Lane,
25   and that's in Hinckley.  The Zip code there
0010
 1   is 44233.
 2   Q    Did you live at this address in
 3   Hinckley, Ohio in June of 1999?
 4   A    Yes, I did.
 5   Q    How long does it typically take you --
 6   A    Uh-huh.
 7   Q    -- to go from your home --
 8   A    Uh-huh.
 9   Q    -- to Parma Community General Hospital?
10   A    Fifteen to 20 minutes.
11   Q    Before you, Dr. Hahn, is a document
12   which we have marked as Exhibit 9.
13   A    Uh-huh.
14   Q    And it has been represented to us that
15   that exhibit, Exhibit 9, is a copy of your
16   curriculum vitae.  So, the question is:  is
17   Exhibit 9 a copy of your curriculum vitae?
18   A    Yeah.  It was current as of probably
19   July or August.  There would be one update
20   on it.
21   Q    Okay.  So, with respect to Exhibit 9,
22   what information is needed to --
23   A    Uh-huh.
24   Q    -- have it current and up-to-date as --
25   as of today?
0011
 1   A    Okay.  Where the third entry under
 2   employment history, obstetrician/
 3   gynecologist for Powers Professional
 4   Corporation, I left employment there at the
 5   end of August of this summer, and I'm now an
 6   obstetrician/gynecologist for Southwest
 7   Obstetrics & Gynecology, Incorporated.
 8   Q    Okay.  Is there any other additions,
 9   corrections or modifications --
10   A    No.
11   Q    -- you would like to make to your
12   curriculum vitae, Exhibit 9?
13   A    No.
14   Q    Then, the facts and statements
15   contained in Exhibit 9, except for the
16   additional information which you have just
17   provided us --
18   A    Uh-huh.
19   Q    -- are true and correct to the best of
20   your knowledge?
21   A    That's correct.
22   Q    All right.  Certain information is
23   omitted from your curriculum vitae.  Let me
24   supplement that.
25   A    Uh-huh.
0012
 1   Q    What is your date of birth?
 2   A    11/10/63.
 3   Q    And where were you born?
 4   A    Cleveland, Ohio.
 5             MR. BONEZZI:   Off the record.
 6             THE VIDEOGRAPHER:   Off the
 7   record.
 8             (At this time a discussion was
 9   held off the record.)
10             THE VIDEOGRAPHER:   Back on the
11   record.
12   BY MR. GORDON:
13   Q    Could you tell me what your Social
14   Security number is?
15   A    294-64-1423.
16   Q    I assume you've never been convicted of
17   a crime.
18   A    No.
19   Q    Is that correct?  Now --
20             MR. BONEZZI:   Say:  that's
21   correct.
22             THE WITNESS:   That's correct.
23   BY MR. GORDON:
24   Q    Okay.  Now -- now, your wife is a
25   physical therapist, and the question I have:
0013
 1   does she work at, or has worked at Parma
 2   Community General Hospital?
 3   A    No.
 4   Q    Okay.  Now, in terms of your medical
 5   education --
 6   A    Uh-huh.
 7   Q    -- you received your degree in medicine
 8   in 1991 from Medical College of Ohio at
 9   Toledo; is that correct?
10   A    That is correct.
11   Q    And, then, eventually you were a
12   resident in obstetrics and gynecology here
13   at University Hospitals of Cleveland; is
14   that correct?
15   A    Yes.
16   Q    And you completed your residency in
17   June of 1995; is that correct?
18   A    Yes.
19   Q    Have you had any further formal
20   education in obstetrics and gynecology?
21   A    No, not other than CME.
22   Q    Okay.  You became Board certified in
23   the American Board of Obstetrics &
24   Gynecology in 1997; is that correct?
25   A    Yes.
0014
 1   Q    Did you pass your boards on your first
 2   attempt?
 3   A    Yes.
 4   Q    Are you Board certified in any other
 5   area of medicine?
 6   A    No.
 7   Q    Now, then, let us discuss at this point
 8   your professional career in obstetrics and
 9   gynecology.
10   A    Uh-huh.
11   Q    After your residency in 1995, did you
12   then go into the private practice of
13   obstetrics and gynecology?
14   A    Yes.
15   Q    And with whom?
16   A    Well, that's changed.  Well, employed
17   -- I was employed by Powers Professional
18   Corporation which is an affiliate
19   corporation of Parma Hospital.
20             MR. JEFFERS:   Object.
21   BY MR. GORDON:
22   Q    At the time you rendered care to Mary
23   Williams in June of 1999, by whom were you
24   employed?
25   A    Powers Professional Corporation.
0015
 1   Q    Were you employed by any other business
 2   entity at the time you took care of Mary
 3   Williams in June of 1999?
 4   A    No.
 5   Q    And when you took care of Mary Williams
 6   in June of 1999, you were acting as an
 7   employee and agent of Powers Professional
 8   Corporation; is that correct?
 9             MR. BONEZZI:   Objection.  That's
10   a legal conclusion.  He was employed, and
11   I'll stipulate to that.
12             MR. GORDON:   Okay.
13             MR. BONEZZI:   And he was acting
14   in the course and scope of his employment.
15             MR. GORDON:   Okay.
16   BY MR. GORDON:
17   Q    Now, where are the offices of Powers
18   Professional Corporation?
19             MR. BONEZZI:   As of June of 1999?
20   BY MR. GORDON:
21   Q    As of June of 1999.  I'm sorry.
22   A    The office that I practiced -- I'm not
23   clear on your question.
24   Q    Okay.  So, that's  -- I'm glad you're
25   telling me that.  Okay.  So, I'll rephrase
0016
 1   my question.
 2             First of all, was there only one
 3   location where Powers Professional
 4   Corporation saw patients?
 5   A    No.
 6   Q    Okay.  Pardon?
 7   A    There were many.
 8   Q    Okay, and I'm going to limit my
 9   questioning, unless you tell me -- unless I
10   tell you otherwise to June of 1999 --
11   A    Uh-huh.
12   Q    -- in this area dealing with Powers
13   Professional Corporation.  Where were
14   offices located in 1999 for Powers
15   Professional Corporation?
16   A    I wouldn't be able to answer that
17   question because there -- it's -- it was a
18   multi-specialty, multi-clinic situation.  I
19   was employed and worked in one office only.
20   Q    What office was that?
21   A    6707 Powers Boulevard, Suite 104.
22   Q    Okay.  Are you -- in June of 1999, were
23   you an officer or director and/or
24   shareholder of Powers Professional
25   Corporation?
0017
 1   A    No.
 2   Q    Did you have a contract with Powers
 3   Professional Corporation at that time?
 4   A    In June of '99?
 5   Q    Yes.
 6   A    Yes.
 7             MR. GORDON:    Okay.  We're going
 8   to make a request for that contract, and
 9   then I'll follow up with a letter, okay?
10             MR. BONEZZI:   That will be fine.
11   BY MR. GORDON:
12   Q    Who was the president of Powers
13   Professional Corporation, to your knowledge,
14   in June of 1999?
15   A    Frances Constantino.
16   Q    Okay.  You indicated earlier there is
17   some association with -- with Parma
18   Community General Hospital with Powers
19   Professional Corporation.
20   A    Uh-huh.
21   Q    Can you explain that, please?
22             MR. JEFFERS:   Objection.
23             THE WITNESS:   I wouldn't -- I
24   wouldn't be able to.
25   BY MR. GORDON:
0018
 1   Q    Is any individual from Powers
 2   Professional Corporation -- strike that.
 3   Was any individuals from Powers Professional
 4   Corporation chairman of the Department of
 5   Obstetrics and Gynecology at Parma Community
 6   General Hospital in June of 1999?
 7   A    I'm sorry.  Rephrase the question
 8   again.
 9             MR. BONEZZI:   Who was the
10   president -- strike that.  Who was the
11   chairman of the department of OB/GYN in
12   1999?
13             THE WITNESS:   It was George
14   Petrie.
15   BY MR. GORDON:
16   Q    Okay, and is Dr. Petrie also employed
17   by Powers Professional Corporation?
18   A    At the time he was, yes.
19   Q    Okay.  Do you have any knowledge
20   whether Powers Professional Corporation had
21   any agreement with Parma Community General
22   Hospital in 1999 regarding the providing of
23   physicians or other medical care providers?
24   A    I have no knowledge of that.
25   Q    Okay.  Maybe you can explain something
0019
 1   for me.  In terms --
 2   A    Uh-huh.
 3   Q    -- of a -- we believe there was an
 4   entity entitled Women & Wellness Center.
 5   A    Uh-huh.
 6   Q    Okay.  What is Women & Wellness Center?
 7   Is that a business entity, or can you
 8   describe it for me?
 9   A    I'm not sure I can answer that in a
10   legal sense.  I can answer it for you that
11   that was sort of the marketing theme that
12   our practice was marketed under.
13   Q    Okay.
14   A    But I wouldn't be able to answer to you
15   whether or not there's a legal entity or a
16   corporation with that title.
17   Q    In June of 1999 at the Women & Wellness
18   Center, other obstetricians and
19   gynecologists practiced with you; is that
20   correct?
21   A    That's correct.
22   Q    Including Dr. Shagawat; am I
23   pronouncing her name right?  Is that
24   correct?
25   A    Yes.
0020
 1   Q    So, Dr. Shagawat practiced with you?
 2   A    Uh-huh.
 3   Q    Is that correct?
 4             MR. BONEZZI:   You have to say
 5   yes.
 6             THE WITNESS:   Yes.
 7   BY MR. GORDON:
 8   Q    Okay.  Forgive me if I keep reminding
 9   you.
10   A    That's all right.
11   Q    Dr. DiCenzo?
12   A    Yes.
13   Q    And Dr. Petrie?
14   A    Yes, Dr. Petrie was on a part-time
15   status I believe at that point.  He was not
16   active in the practice of -- of obstetrics
17   at that point.
18   Q    All right.  Then, your career since the
19   end of your residency until the end of
20   August, 1999 has been with Powers
21   Professional Corporation.
22   A    That's correct.
23   Q    In June of 1999, were you licensed to
24   practice medicine in the state of Ohio?
25   A    Yes.
0021
 1   Q    Had your license to practice medicine
 2   in the state of Ohio ever been revoked or
 3   suspended for whatever reason?
 4   A    No.
 5   Q    Do you have or have you had any license
 6   to practice medicine in any other states --
 7   A    No.
 8   Q    -- other than the State of Ohio?
 9   A    No.
10   Q    In June of 1999, be -- besides Parma
11   Community General Hospital, did you have
12   privileges to practice obstetrics and
13   gynecology at any other hospital?
14   A    Yes.
15   Q    What other hospitals?
16   A    University Hospitals of Cleveland, and
17   The Surgery Center which is on Bagley Road
18   in Middleburg Heights.
19   Q    This surgery center on Bagley Road --
20   A    Uh-huh.
21   Q    -- is associated with what hospital?
22   A    It was owned by Columbia.
23   Q    That's where St. John & West Shore is
24   located?
25   A    No, no.  It's a separate, freestanding
0022
 1   center.
 2   Q    Oh, okay.  Do you still have privileges
 3   at those  --
 4   A    Uh-huh.
 5   Q    -- hospitals or institutions?
 6   A    Uh-huh.
 7   Q    Is that correct?
 8   A    Yes.
 9   Q    Okay.  Has your hospital privileges at
10   any time ever been revoked or suspended at
11   any institution --
12   A    No.
13   Q    -- for whatever reason?
14   A    (At this time the witness shook his
15   head.)
16   Q    Okay.  Which means among other things
17   you keep your Discharge Summary and your
18   charts current and up-to-date; is that
19   correct?
20   A    That's correct.
21   Q    Okay.  What professional associations
22   are you or have you been a member of?
23   A    I'm a fellow in the American College
24   --
25   Q    Are they listed on the page?
0023
 1   A    They're listed, yes, yes.
 2   Q    Okay.  We don't have to repeat that.
 3   They're listed on page two --
 4   A    Yes.
 5   Q    -- of your CV, Exhibit 9?
 6   A    Yes.
 7   Q    Have you had any academic appointment
 8   from any institution in regard to teaching
 9   in the field of medicine?
10   A    Yes.  I'm a clinical instructor in the
11   School of Medicine at Case Western Reserve
12   University.
13   Q    Do you give lectures there?
14   A    No.  I -- primarily third-year medical
15   students spend a portion of their core
16   clerkship in my office one day a week for an
17   eight-week rotation each year.
18   Q    Okay.  In terms of the publications
19   that you have authored, those are identified
20   in your CV; is that correct?
21   A    Yes.
22   Q    Are there any other publications --
23   A    No.
24   Q    -- that you've authored?  Okay.  Have
25   you ever been deposed before?
0024
 1   A    Once.
 2   Q    And did that involve a case of alleged
 3   medical malpractice?
 4   A    Yes.
 5   Q    Were you a named party to that lawsuit?
 6   A    Yes.
 7   Q    Do you know the name of that lawsuit?
 8   A    I remember the plaintiff's name.  It
 9   was Kimberly Smith.
10   Q    And -- and did that arise in Cuyahoga
11   County?
12   A    Yes, uh-huh.
13   Q    Was Parma Community General Hospital
14   also a defendant in that lawsuit?
15   A    No, Powers Professional Corporation
16   was.
17   Q    Okay.  Is that case still pending?
18   A    No.
19   Q    By the fact you've had your deposition
20   taken before, you're somewhat familiar with
21   the deposition process?
22   A    Uh-huh, yes.
23   Q    In that case, the Smith case, did you
24   testify in court?
25   A    No.
0025
 1   Q    Who represented you?
 2   A    Um, it was PIE's plaintiff firm.  I'm
 3   blanking on the gentleman's name.
 4   Q    Were you represented by a member of
 5   Jacobson, Maynard, Tuschman & Kalur?
 6   A    Yes, yes.
 7   Q    But not Mr. Bonezzi?
 8   A    No.
 9   Q    Now, have you ever acted as an expert
10   witness?
11   A    No.
12   Q    Now, before June 26th, 1999 -- let me
13   rephrase that.
14             Before June 25th, 26th, 1999, you
15   had worked with Dr. Hsieh before?
16   A    Yes.
17   Q    And can we agree that you had been
18   working with Dr. Hsieh since the time you
19   began practicing obstetrics and gynecology
20   at Parma Community General Hospital?
21   A    Honestly, I -- I don't recall when I
22   first encountered him.
23   Q    Okay.  It would have been a
24   relationship that had been going on, working
25   relationship that had been going on with Dr.
0026
 1   Hsieh for more than a year before June 25th,
 2   1999?
 3   A    I -- I honestly can't say for certain.
 4   Q    Okay.  In your relationship with Dr.
 5   Hsieh, have you had difficulties
 6   communicating with him?
 7             MR. BONEZZI:   Objection.  Go
 8   ahead and answer.
 9             MR. SCHOBERT:  Objection.
10             THE WITNESS:   No.
11   BY MR. GORDON:
12   Q    You've had no problem talking to him or
13   understanding him?
14   A    I've had to have him repeat what he
15   says on occasion.
16   Q    And why do you do that?
17   A    Because of his thick accent.
18   Q    And you've had communications with Dr.
19   Hsieh both in person and over the telephone;
20   am I correct?
21   A    Yes.
22   Q    Okay.
23             (At this time David Paris, Esq.
24   entered the deposition.)
25   BY MR. GORDON:
0027
 1   Q    Do you consider that when Dr. Hsieh
 2   attends to patients of yours, such as Mary
 3   Williams --
 4   A    Uh-huh.
 5   Q    -- that he -- he is required to follow
 6   the accepted standard of care of an
 7   obstetrician and gynecologist?
 8   A    Yes.
 9             MR. BONEZZI:   Objection.
10   Objection to the form of the question.
11   That's fine.
12             THE WITNESS:   Uh-huh.
13   BY MR. GORDON:
14   Q    Your answer is still yes?
15   A    Yes.
16   Q    Okay.  Prior to June 25th, 1999, had
17   you ever worked with Ms. Prokop?
18   A    I mean, I wouldn't be able to recall a
19   specific instance of working --
20             MR. BONEZZI:   No.  He asked
21   whether or not, prior to June 25th, '99, you
22   had worked with Paula Prokop or Ms. Prokop.
23             THE WITNESS:   Yes.
24             MR. BONEZZI:   Yes or no?
25             THE WITNESS:   Yes.
0028
 1   BY MR. GORDON:
 2   Q    Okay, and did you have a good working
 3   relationship with her?
 4   A    Yes.
 5   Q    And did you have a good working
 6   relationship with Dr. Hsieh?
 7   A    Yes.
 8   Q    There's another nurse identified in the
 9   records, a nurse -- her name is, and Mr.
10   Jeffers, I hope, can help me, is Mary
11   Hulvalchick.
12   A    Yes.
13   Q    And had you worked with her before June
14   25th, 1999?
15   A    Yes.
16   Q    And you had a good working relationship
17   with them?
18   A    Yes.
19   Q    Okay, and also another nurse is Debbie
20   Bazzo.  Are you familiar with her?
21   A    Yes.
22   Q    And you had worked with her before June
23   25th, 1999?
24   A    Yes.
25   Q    And no difficulty working with her?
0029
 1   A    No.
 2   Q    Do you remember Mary Elizabeth Williams?
 3   A    Yes.
 4   Q    And do you have a clear memory of your
 5   involvement with your care and treatment of
 6   Mary Williams in June of 1999?
 7   A    Yes.
 8   Q    Can you describe her for me?
 9   A    Yes.
10   Q    Could you do that, please?
11   A    She had blond hair, was of medium
12   build, fair-skinned.
13   Q    Did you ever meet Mary Williams's
14   husband?
15   A    Yes.
16   Q    And when was the first time you met Mr.
17   Williams?
18   A    I do not recall.
19   Q    Can you describe him for me?
20   A    Not from memory, not real well, no.
21   Q    Did you ever meet Mary Williams's
22   mother?
23   A    Yes.
24   Q    Okay, and can you describe her for me?
25   A    She also is fair-skinned, brown hair;
0030
 1   short, brown hair.
 2   Q    Now, I want to discuss with you now a
 3   little bit about your practice in obstetrics
 4   and gynecology in -- in June of 1999, or are
 5   you better able for that year before June of
 6   1999; in terms of the time you spent in
 7   obstetrics and gynecology, could you give me
 8   a percentage on average?
 9   A    I would say probably 65 percent
10   gynecology, 35 percent obstetrics, but
11   that's a guesstimate.  I don't have any hard
12   numbers in my head to present.
13   Q    All right.  I understand that's just an
14   estimate, okay.
15   A    Uh-huh.
16   Q    Or an approximation.
17   A    Uh-huh.
18   Q    But it's a fair approximation?
19             MR. BONEZZI:   Objection.  He just
20   said that he doesn't have anything to -- to
21   base it on.
22             MR. GORDON:   Okay.
23             MR. BONEZZI:   So, don't ask him
24   about a fair approximation.  He gave you the
25   best numbers that he could.
0031
 1             MR. GORDON:   All right.   I
 2   didn't mean to --
 3   BY MR. GORDON:
 4   Q    But you have a reasonable basis for
 5   giving me those figures; is that correct?
 6   A    Yes.
 7   Q    Okay.  I mean -- all right.  Now, on
 8   average, let's say, for that one-year period
 9   before June of 1999, how many babies did you
10   deliver per month or per week or whatever
11   way you calculate that?
12   A    Uh-huh.  My average at that time was
13   ten to 12 deliveries per month.
14   Q    Now, in -- in your experience, say, as
15   of June 25th, 1999, had you had any of your
16   patients develop a post-delivery infection
17   within 24 hours of the delivery?
18   A    Yes.
19   Q    How many patients approximately?
20   A    Oh, I -- I couldn't estimate for you.
21   Q    Is that something common or uncommon?
22   A    It is relatively uncommon, but it
23   depends on the circumstances.
24   Q    What circumstances?
25   A    Mode of delivery.
0032
 1   Q    And mode of delivery would be what?
 2   A    Vaginal versus Cesarean section.
 3   Q    And you -- you expect to have more
 4   post-delivery infections, am I correct, when
 5   you have a delivery effectuated by a
 6   Cesarean section?
 7   A    Correct.
 8   Q    And why is that?
 9   A    There's a much greater opportunity for
10   colonization of the upper genital tract.
11   Q    And you've had -- have you had in your
12   experience, nonetheless, that post-delivery
13   infection within 24 hours with a patient who
14   had a vaginal delivery?
15   A    Yes.
16   Q    Okay.  In your experience before June
17   25th, 1999, had -- had you ever had a
18   patient who developed a severe infection
19   within 24 hours of the delivery?
20   A    No.
21   Q    Is Mary Williams the only patient that
22   you had that developed a severe infection
23   within 24 hours of the delivery?
24   A    Again, no.
25   Q    You had other ones?
0033
 1   A    Yes.  Your -- your question changed.
 2   Q    Okay.  Let me -- let me -- maybe I lost
 3   my -- I'll strike the question.
 4   A    Okay.
 5   Q    Is Mary Williams the only patient that
 6   you've treated that, let's say -- let me
 7   strike the question.
 8             Before June 25th, 1999 -- 1999,
 9   was Mary Williams the only patient that you
10   treated who -- who had developed an
11   infection within 24 hours of the delivery?
12   A    No, but again you changed the question.
13   Q    All right.  How --
14   A    You were discussing modes of delivery,
15   and I answered the question previously that,
16   yes, I've taken care of patients who have
17   delivered and developed a severe infection
18   within 24 hours.
19             MR. JEFFERS:   You also started
20   with "severe" and then dropped the word
21   "severe."
22   BY MR. GORDON:
23   Q    Okay, okay.  So, let me rephrase that.
24   With respect to -- all right, let me clarify
25   then.  With respect to patients that you had
0034
 1   who had an infection within 24 hours of
 2   delivery before June 25th, 1999, you've had
 3   patients like that?
 4   A    Yes.
 5   Q    Okay.  Both in the area of vaginal
 6   delivery as well as Cesarean section?
 7   A    No.
 8   Q    Okay.  Were the ones before June 25th,
 9   1999 that you had seen who did develop an
10   infection within 24 hours of the delivery
11   those that had a Cesarean section?
12   A    Cesareans or a very complicated vaginal
13   delivery where a patient may have an
14   infection prior to delivery --
15   Q    Okay.
16   A    -- or significant risk factors.
17   Q    So, then, Mary Williams was the first
18   patient that you had that developed an
19   infection within 24 hours of the delivery --
20   A    No.
21   Q    -- from a vaginal delivery?
22   A    Yes.
23   Q    Okay.  Have you -- strike that.
24             How about since June 25th, 1999;
25   have you had patients who developed an
0035
 1   infection within 24 hours of the delivery?
 2             MR. BONEZZI:   Objection.
 3             THE WITNESS:   No
 4             MR. BONEZZI:   That's fine.
 5   BY MR. GORDON:
 6   Q    Now, changing the question,
 7   unfortunately, has -- has any of your
 8   patients that you have treated died from a
 9   delivery -- died from a post-delivery
10   infection?
11   A    No.
12   Q    Is Mary Williams the only patient of
13   yours that has died from a post-delivery
14   infection?
15   A    Yes.
16   Q    In your -- I won't go into -- I won't
17   go into any great detail at this point, but
18   one of the things that you noted in your
19   Discharge Summary report was the fact that
20   one of the diagnoses was toxic shock
21   syndrome.
22   A    Uh-huh.
23   Q    If you want to look at it, it's -- it's
24   found on page one of Exhibit 5.
25   A    Uh-huh.
0036
 1             MR. BONEZZI:   You've got it.
 2   BY MR. GORDON:
 3   Q    What is toxic shock syndrome?
 4   A    Toxic shock syndrome is a -- a systemic
 5   disorder caused by toxins released by
 6   bacteria, usually -- sometimes from a focal
 7   infection.
 8   Q    You also in your Discharge Summary
 9   report, you used the term, sepsis.
10   A    Uh-huh.
11   Q    Also the term, septicemia.
12   A    Uh-huh.
13   Q    Do you use those words interchangeably?
14   A    Yes.
15   Q    What is -- strike that.
16             And also you used --
17   A    Uh-huh.
18   Q    -- I think the term septic syndrome or
19   sepsis syndrome.  Is that also synonymous
20   with sepsis?
21   A    Uh-huh.
22   Q    And septicemia?
23   A    Uh-huh.
24   Q    Is that correct?
25   A    Yes.
0037
 1   Q    What is, then, sepsis?
 2   A    It's a disseminated infection.  Usually
 3   -- it usually implies hematologic spread of
 4   infection.  Sepsis syndrome may imply a --
 5   an alteration in a person's physiologic
 6   adaptation to that infection.
 7   Q    When you -- I think you said
 8   hematologic changes.  Is that what you said?
 9   A    No, hematologic evidence.
10   Q    Okay.
11   A    In terms of the -- both -- positive
12   blood culture would be the --
13   Q    Okay, okay.  Have -- is Mary Williams
14   the only patient that you had that died from
15   sepsis and toxic shock syndrome?
16   A    Yes.
17   Q    Now, to prepare yourself for your
18   deposition today --
19   A    Uh-huh.
20   Q    -- have you looked at any documents,
21   materials?
22   A    Uh-huh.  The medical record for the
23   patient.
24   Q    So, to clarify that, you looked at her
25   complete chart?
0038
 1   A    Uh-huh.
 2   Q    Is that correct?
 3   A    Yes.
 4   Q    Did you look at the records from the --
 5   I'll get this name right; Women & Wellness
 6   Center?
 7   A    Actually, I did not review those, the
 8   antepartum records, although they were part
 9   of the records I had for review.  I -- I
10   think I saw her a total of three times for
11   her prenatal care.
12   Q    Have you reviewed any other materials
13   to prepare yourself for your deposition
14   today other than the chart --
15   A    No.
16   Q    -- of Mary Williams?  In other words,
17   did you do any research?
18   A    Uh-huh.
19   Q    Things of that -- is that --
20   A    That's correct, no.
21   Q    Talk to any physicians?
22   A    No.
23   Q    Now, Mary Williams for her prenatal
24   care was a patient - I'll get the name - of
25   Powers Professional Corporation.
0039
 1   A    That would be correct.
 2   Q    And was -- was her attending
 3   obstetrician Dr. Shagawat, or if I'm
 4   incorrect, can you explain that?
 5   A    I'm not certain.  At the time, the
 6   prenatal care was often shared in our
 7   practice, but many times a patient might
 8   identify with one physician and see them
 9   more commonly, and I believe that Mary
10   Williams saw Dr. Shagawat more commonly than
11   the rest of us.
12   Q    Okay, and apparently it would have been
13   explained to the patient that in the event,
14   what?  Dr. Shagawat was unavailable for the
15   labor and delivery --
16   A    Uh-huh.
17   Q    -- some other physicians from that
18   group would be attending to her.
19   A    We actually had a schedule of who
20   covered labor and delivery, and the patients
21   were aware of that.
22   Q    Okay.
23   A    It was not -- they understood that any
24   one of the three of us would be present for
25   their birth.
0040
 1   Q    The other would be Dr. --
 2             MR. BONEZZI:   DiCenzo.
 3             MR. GORDON:    DiCenzo.
 4             THE WITNESS:   Yes.
 5   BY MR. GORDON:
 6   Q    By the way, why did you leave Powers
 7   Professional Corporation?
 8             MR. JEFFERS:    Objection.
 9             MR. BONEZZI:   Objection.  Go
10   ahead and answer.
11             THE WITNESS:   I started my own
12   practice.
13   BY MR. GORDON:
14   Q    Okay, and what's the name of your
15   practice, or are you associated with anyone?
16   A    Southwest Obstetrics & Gynecology,
17   Incorporated.
18   Q    Okay.  Is that the name of your
19   practice?
20   A    Yes.
21   Q    Are you associated with any other
22   obstetrician, gynecologist?
23   A    No.
24   Q    Now, at this point, I would like to go
25   to the chart --
0041
 1   A    Uh-huh.
 2   Q    -- and have you identify -- excuse me.
 3   I'm losing my cough drop.
 4   A    Uh-huh.
 5   Q    -- have you identify for us those
 6   portions of the record that you prepared,
 7   okay, and, then, those that are handwritten,
 8   I would like for you to interpret --
 9   A    Okay.
10   Q    -- those items, okay?
11   A    Uh-huh.
12             MR. BONEZZI:   Why don't you look
13   at the progress notes first.
14             THE WITNESS:   Okay.
15             MR. BONEZZI:   And we'll start
16   from there.
17   BY MR. GORDON:
18   Q    Now --
19             MR. BONEZZI:   Take a moment, and
20   just go through there.
21             THE WITNESS:   Uh-huh.
22             MR. BONEZZI:   And see which notes
23   may be yours.
24   BY MR. GORDON:
25   Q    Maybe I can help you, Doctor, and then
0042
 1   -- then we can go back.
 2   A    Uh-huh.
 3   Q    I've identified the following records
 4   that you prepared in the progress notes.
 5   A    Uh-huh.
 6   Q    And --
 7             MR. BONEZZI:   What's the Bates
 8   number?
 9             MR. GORDON:   Yeah, I will.  I'm
10   just going to --
11             MR. JEFFERS:   Give the Bates
12   stamp in the right corner.
13   BY MR. GORDON:
14   Q    Okay.  Page 190.
15   A    Uh-huh.
16   Q    Is that correct?
17   A    (At this time the witness nodded his
18   head.)
19   Q    Your progress notes on that page.
20   A    Uh-huh.
21             MR. BONEZZI:   You have to say
22   "yes."
23   BY MR. GORDON:
24   Q    Page one --
25   A    Yes.
0043
 1   Q    Page 191 you wrote a progress note.
 2   A    Yes.
 3   Q    And on page 193.
 4   A    Yes.
 5   Q    Okay.  Is that all the progress notes
 6   that you wrote --
 7   A    Yes.
 8   Q    -- regarding Mary Williams?
 9   A    Uh-huh.
10   Q    Is that correct?
11   A    That's correct.
12   Q    Okay.  You also wrote, according to my
13   review of the chart, some orders, and let me
14   go and give you the page numbers.  When I
15   say "wrote," I mean either you, yourself
16   wrote them --
17   A    Uh-huh.
18   Q    -- or you gave orders for them to be
19   written on your behalf.
20   A    Uh-huh.
21   Q    Okay?
22   A    Uh-huh.
23   Q    And those orders are -- appear on page,
24   first of all, 179; is that correct?
25   A    Yes.
0044
 1   Q    One eighty.
 2   A    Yes.
 3   Q    One eighty-one.
 4   A    Yes.
 5   Q    Is that the extent of the orders that
 6   you wrote on Mary Williams?  Did you want --
 7             MR. JEFFERS:   I think he's
 8   looking at your 5 and not at the complete
 9   chart.
10             THE WITNESS:   This is incomplete,
11   correct?
12   BY MR. GORDON:
13   Q    Yes.
14   A    Yes.
15   Q    Do you want to look at the complete
16   chart?  Because I thought you reviewed the
17   record, and I thought I could go over that
18   with you without -- but go ahead, if you
19   want to look at it.
20   A    Uh-huh.
21   Q    I'm not here to trick you.  I just want
22   to --
23   A    No, I want to -- there --
24             Actually, on page 184, there is
25   an order written by myself.
0045
 1   Q    Okay.  I'm glad I had you do that,
 2   then.  Okay.  Is there any other?
 3   A    And page 185.
 4   Q    Okay, okay.  Could you go back, then,
 5   to the progress notes to see if there are
 6   any additional progress notes that you wrote
 7   that I -- that you and I did not identify
 8   earlier?
 9   A    No, the rest are just complete.
10   Q    Okay, and the other thing that you
11   wrote that I could determine is your
12   Discharge Summary report --
13   A    Uh-huh.
14   Q    -- found on pages one, two and three;
15   is that correct?
16   A    Actually, it's page five, four, three.
17   Q    I'm sorry.
18   A    Two --
19   Q    I'm looking at -- forgive me.
20   A    -- actually page three, four, five.
21   Q    All right.  I'm looking at the -- all
22   right, the Discharge Summary report is
23   identified in our Exhibit 5 as three, four
24   and five, okay; am I correct?
25   A    Yes.
0046
 1   Q    Okay.  So, we've covered all the
 2   records that you wrote.
 3   A    Uh-huh.
 4   Q    Is that correct?
 5   A    Yes.
 6   Q    Do you have any other notes that you
 7   prepared regarding Mary Williams which you
 8   have retained?
 9   A    No.
10   Q    So, the -- all the -- all the notes
11   that you wrote are either in the chart at
12   Parma Community General Hospital or in the
13   Women & Wellness Center records.
14   A    That's correct.
15   Q    Did you give any written statement to
16   anyone about your involvement in the care
17   and treatment of Mary Williams?
18   A    No.
19   Q    All right.  Now, let's go to the
20   progress notes first.
21   A    Uh-huh.
22   Q    Now, am I correct, the first row --
23   strike that.
24             Am I correct that the first note
25   that you wrote, progress note is on page 190
0047
 1   dated June 26, 1999, 9:20 a.m.?
 2   A    Uh-huh.
 3   Q    Is that correct?
 4   A    That's correct.
 5   Q    Am I correct, then, that the first time
 6   you saw Mary Williams during the
 7   hospitalization, June 25th, June 26th, 1999,
 8   was some time around nine a.m. on the
 9   morning of June 26th, 1999?
10   A    I believe that's probably incorrect.  I
11   believe I saw her before that.
12   Q    Okay.  What time do you believe you saw
13   Mary Williams?
14   A    Let me look back at the nurse's notes.
15   It was probably around nine or shortly
16   before that.
17   Q    The nurse's note on page 160 at 0900 on
18   June 26th, '99 indicates, "Dr. Hahn in to
19   see the patient."
20   A    Uh-huh.
21   Q    Am I correct?  I'm reading it right?
22   A    Yes.
23   Q    So, can we rely upon that documentation
24   that you saw --
25   A    Uh-huh.
0048
 1   Q    -- Mary Williams for the first time on
 2   June 26th, 1999 at nine a.m. in the morning?
 3   A    That's correct.
 4   Q    Okay.  However, the records do indicate
 5   that you had involvement in Mary Williams's
 6   care and treatment before nine a.m., June
 7   26th, 1999 by means of telephone.
 8   A    That's correct.
 9   Q    Now, turning to the progress note on
10   page 190 --
11   A    Uh-huh.
12   Q    -- could you please read for us your
13   note in its entirety?
14   A    Uh-huh.
15   Q    And when there is an abbreviation,
16   could you please interpret that abbreviation
17   for us?
18   A    Okay.
19   Q    And please go slowly for the court
20   reporter.
21   A    Sure.
22   Q    And us.
23   A    My "S" is subjective.  "Patient's
24   restless with abdominal pain, continuous and
25   sharp."  I listed her vital signs as a pulse
0049
 1   of 109, a blood pressure of 90 over 60, a
 2   pulse ox of 98 percent, and that her urine
 3   output had been approximately 40 ccs per
 4   hour.
 5             On examination, LCTA stands for
 6   her lungs are clear to auscultation.
 7   There's a slash, and what follows is "RRR"
 8   which stands for regular rate and rhythm,
 9   which would be her cardiac examination.  Her
10   abdomen appeared distended.  Bowel sounds
11   were absent, and she was tender in the
12   epigastrium.
13             And, the examination of her
14   extremities was "neg" is negative.  "EXT" is
15   extremities, and I wrote that her "DTRs,"
16   which stands for deep tendon reflexes, were
17   one plus.  "Assessment/plan, rule out
18   intra-abdominal hemorrhage or liver capsule
19   rupture."
20   Q    Or what?
21   A    Liver capsule rupture.  "Stat CT scan.
22   CBC.  Fibrin split products.  PT, PTT and
23   magnesium."
24   Q    And that's your initials or signature?
25   A    That's my signature.
0050
 1   Q    Okay.  Then, you wrote another note
 2   also on page 190; is that correct?
 3   A    Uh-huh, yes.
 4   Q    And that -- okay.  Now, the 9:20 time
 5   for the first note on page 190, is that the
 6   time you wrote the note or the time you saw
 7   the patient?
 8   A    It would be the time I wrote the note.
 9   Q    Okay.  Then, at the bottom of the page,
10   you have written a note for 10:30 on June
11   26th, 1999.  That's 10:30 a.m.; is that
12   correct?
13   A    Uh-huh.
14   Q    Is that correct?
15   A    Yes.
16   Q    Okay.  Forgive me for that, but --
17   A    I understand.
18   Q    Okay.  Could you please read, then, the
19   note that you wrote on page 190 --
20   A    Uh-huh.
21   Q    -- at 10:30 a.m?
22   A    Sure.  The results, patient had an
23   arterial blood gas.  Do you want me to read
24   the numbers to you?  It's her pH was 7.27,
25   19.6, 75.6, 93 percent, 0.9 and 12.7, and
0051
 1   the patient had an AA gradient of 47.3.  The
 2   CT scan revealed no intra-abdominal bleed.
 3   Q    It says "negative bleeding"?
 4   A    Right.  EKG showed a normal sinus
 5   rhythm with no acute changes.  Her labs in
 6   the matrix would reveal a white count of
 7   2.5, a hemoglobin of 13.0, a hematocrit of
 8   38.3, a platelet count of 145, and
 9   differential pending.  Her PTT was 56.  Her
10   PT was 13.  Her magnesium was 8.0.  Her SGOT
11   was 65, and her SGPT was 36.  "Impression:
12   rule out pulmonary embolism," and I ordered
13   a stat VQ scan and to begin heparin, and
14   given the white count, I was concerned about
15   possible sepsis, so I drew two sets of blood
16   cultures, and I was awaiting the
17   differential to come back.
18   Q    What about the white blood count
19   concerned you that there might be sepsis?
20   A    It was a low white count.
21   Q    The 2.5?
22   A    Yes.
23   Q    Okay.  Then, at the bottom of the note
24   on page 190, is that your signature?
25   A    Yes.
0052
 1   Q    Turn to the next page, page 191.
 2   A    Uh-huh.
 3   Q    There's a progress note that you wrote
 4   at the top of the page.
 5   A    Uh-huh.
 6   Q    Is that correct?
 7   A    Yes.
 8   Q    It's dated June 26th, 1999?
 9   A    Uh-huh.
10   Q    But it's untimed.
11   A    Uh-huh.
12   Q    Is that correct?
13   A    Yes.
14   Q    Are you able to give us a reasonable
15   time frame as to when this progress note was
16   written?
17   A    About the time the patient was
18   transferred to ICU.  I don't recall the
19   exact time of that.
20   Q    I think --
21   A    This was actually done as -- like, when
22   the patient was transferred to ICU, I
23   followed her and wrote the note there.
24   Q    Did the nurses' notes -- a decision to
25   transfer was made at 12:45 on page 160.
0053
 1   A    Actually, no.  It was at 10:45 on page
 2   160.
 3   Q    10:45?
 4   A    Yes.
 5   Q    Okay.  So, the -- the note on page 191
 6   would be written approximately around 10:45
 7   a.m.
 8   A    That would be correct.
 9   Q    Okay.  Could you now read the note
10   again in its entirety and interpret your
11   abbreviations?
12   A    Uh-huh.
13   Q    Please.
14   A    It says, "Patient with hypotensive
15   episode."  "TX" is transferred to ICU.  On
16   arrival her BPs, the blood pressures, were
17   there at 130 over 70, and Trendelenburg.
18   Heparin IV was started.  Unasyn was started.
19   Triple lumen to be placed by the house --
20   house intensivist, house officer and a
21   consult to Dr. Wolfson's group.  Dr. Wolfson
22   is an intensivist and pulmonologist.  My
23   impression was:  "Rule out sepsis.  Rule out
24   PE.  Pulmonary ID. consults.  VQ scan when
25   stable and heparin, Unasyn, Gentamicin,
0054
 1   Clindamycin.
 2   Q    And that's your signature?
 3   A    Yes.
 4   Q    One thing, just could you backtrack to
 5   the -- the note on -- on page 190?
 6   A    Uh-huh.
 7   Q    You indicated with respect to the
 8   complete blood count that the differential
 9   was pending.  What does that mean?
10   A    That's looking at the -- the makeup of
11   the types of white cells that are present in
12   the smear or what percentage of different
13   forms of white cells may be present.
14   Q    That's what we call, and I am getting
15   back to this, the bands, the neutrophils?
16   A    Right.
17   Q    Metamyelocytes?
18   A    Right.
19   Q    And how did you know the differential
20   was pending?  Physically, how --
21   A    Physically, they hand us -- when the
22   results come to the floor, they're printed
23   out on the computer, and they're handed to
24   us.
25   Q    Okay.  That means the nurse would have
0055
 1   handed that to you?
 2   A    A nurse or a ward secretary.  I don't
 3   recall specifically in this instance how.
 4   Q    And then on that document that's handed
 5   to you, there's something to indicate that
 6   -- that the differential is pending?
 7   A    That's correct.
 8   Q    By saying "pending," or something or
 9   some language?
10   A    I believe it says "pending," or there's
11   Ps there.
12   Q    Okay.  Now, could you please turn to
13   the progress note written on page 193?  Now,
14   you wrote the progress note at the top of
15   the page?
16   A    Uh-huh.
17   Q    And it's time is June 26, 1999 at 1650
18   or 4:50 p.m.?
19   A    Uh-huh.
20   Q    Is that correct?
21   A    Uh-huh.
22   Q    Yes?  Is that correct?
23   A    4:50, yes.
24   Q    Okay.  Could you now read that note in
25   its entirety, please?
0056
 1   A    Okay.  Let's see.  Patient's on 20
 2   micrograms of Dopamine, 34 micrograms of
 3   Levophed with decreased blood pressures 80s
 4   over 40s, with metabolic acidosis corrected
 5   or down to the 7.30.  She's on Flagyl,
 6   nafcillin and Primaxin for apparent toxic
 7   shock syndrome.  "Status post intubation for
 8   oxygenation."  The heparin was DCed
 9   secondary to increased PTT.  With patient
10   may need additional support, will transfer
11   to tertiary care center."
12   Q    "With patient" what?  I didn't hear.
13   A    "Needing additional support."
14   Q    Okay, and that's your signature?
15   A    Yes.
16   Q    And have we now completed all the
17   progress notes that you wrote?
18   A    Yes.
19   Q    Okay.  Now, let's turn to the -- the
20   orders.  Am I correct that the first order
21   -- first order that is under your signature
22   is on page 179?
23   A    Uh-huh.
24   Q    The top of the page, June 25th --
25   A    Uh-huh.
0057
 1   Q    -- 1500 or three p.m.; is that correct?
 2   A    Yes.
 3   Q    Is this your writing?
 4   A    No.  This was a verbal order.  The
 5   labor and delivery had called the office,
 6   and I just happened to be the physician in
 7   the office who took the phone call.
 8   Q    Okay.
 9   A    I don't recall the specific instance of
10   -- if they lost the type and screen from
11   admission or --
12   Q    Okay.  Could you read the -- the order
13   for us?
14   A    "Type and screen Rhogam as needed.
15   Phone order Dr. Hahn."
16   Q    And do you recognize that -- the
17   nurse's signature?
18   A    I do not.
19   Q    Then later you came back, and you
20   signed the order; is that correct?
21   A    Countersigned, yes.
22   Q    Countersigned, okay.  Now, the next
23   order under your signature on page 179, is
24   that 2020 or 8:20 p.m. on June 25th, or is
25   it the 1550 order?
0058
 1   A    I think it's -- well, Dr. Hsieh wrote
 2   an order at 1550, and I think he wrote my
 3   name under his name, and as such, the
 4   medical records people flagged it as a
 5   verbal order to be countersigned.
 6   Q    Okay, and what's the order?
 7   A    "Repeat serum magnesium at 17 p.m.,"
 8   and he wrote under that "CBC."
 9   Q    Okay, and you countersigned the order?
10   A    Yes.
11   Q    And this order is at 3:50 p.m.?
12   A    Uh-huh.
13   Q    Is that correct?
14   A    Yes.
15   Q    Okay.  Then, the next order is at 2020
16   or 8:20 p.m.; is that correct?
17   A    Uh-huh.
18   Q    Is that correct?
19   A    Yes.
20   Q    Okay, and could you read that?
21   A    "Obtain urine sample from catheter for
22   culture and sensitivity.  Labs, mag level,
23   SGOT, SGPT and CBC Q 6 hours."
24   Q    And you later co-signed --
25   A    Yes.
0059
 1   Q    -- or countersigned it.  Then, the next
 2   order under your name is at 0045 or 12:45
 3   a.m. on June 26th, 1999; is that correct?
 4   A    That's correct.
 5   Q    And could you read that for us?
 6   A    "May give Ativan one-half milligram IV
 7   stat and may repeat up to one milligram Q 8
 8   hours prn for anxiety, restlessness."
 9   Q    And that's -- "TO" is a telephone
10   order?
11   A    Yes.
12   Q    And you countersigned that?
13   A    Yes.
14   Q    Okay.  Then, on page 180, these are all
15   your orders; is that correct?
16   A    Yes.
17   Q    Okay.  The first order on page 180 is
18   from June 26th, 0345 or 3:45 a.m.
19   A    Uh-huh.
20   Q    Could you read that for us, please?
21   A    "Give one liter of lactated ringers
22   over next hour and resume rate of 75 ccs per
23   hour."
24   Q    Okay, and you countersigned that order.
25   A    Yes.
0060
 1   Q    The next order is at 0720 or 7:20 a.m.
 2   on June 26th.
 3   A    Uh-huh.
 4   Q    Is that correct?
 5   A    Yes.
 6   Q    Could you read that order?
 7   A    "Turn magnesium sulfate off now.  May
 8   have Motrin 800 milligrams Q 8 hours p.o."
 9   Q    And it's a telephone order?
10   A    Yes.
11   Q    Telephone order being that it was --
12   the order was given over the telephone.
13   A    That would be correct.
14   Q    A verbal order is that you verbally
15   tell the nurse, whoever, to write the order
16   while you're talking to the nurse or the
17   other person you're asking to write the
18   order.  Is that about right?
19   A    That's up for interpretation.  A verbal
20   order is a verbal -- I mean, it could be
21   given by phone, or it could be given
22   verbally in person.
23   Q    The next order on page 180 is 0930 or
24   9:30 a.m. on June 26th, 1999; is that
25   correct?
0061
 1   A    Yes.
 2   Q    Could you read that, please?
 3   A    "Stat magnesium sulfate level.  CBC.
 4   SGOT, SGPT, fibrinogen split products.  PT,
 5   PTT, and stat CT of abdomen."
 6   Q    And you countersigned that?
 7   A    Yes.
 8   Q    And the next order is at 1000 or 10:00
 9   A.M. on June 26th, 1999?
10   A    Uh-huh.
11   Q    Is that correct?
12   A    Yes.
13   Q    Could you read that, please?
14   A    "Blood culture times two sites.  Blood
15   gas, Unasyn three grams IV Q six hours after
16   blood culture is done."
17   Q    Okay.  Is there any of your writing in
18   this order other than your signature?
19   A    The Unasyn.
20   Q    Okay.
21             MR. JEFFERS:   Pardon me?
22             THE WITNESS:   The order for the
23   Unasyn was in my handwriting.
24   BY MR. GORDON:
25   Q    Okay.  Then you countersigned that
0062
 1   order?
 2   A    Yes.
 3   Q    Then, at the bottom of the page, 180,
 4   there's an order, untimed, June 26th, '99?
 5   A    Uh-huh.
 6   Q    Is that correct?
 7   A    Yes.
 8   Q    And could you read that?
 9   A    "12-lead EKG."
10   Q    Okay, and you countersigned that?
11   A    Yes.
12   Q    Then, the next order is found on page
13   181?
14   A    Uh-huh.
15   Q    And that's at the top of the page?
16   A    Uh-huh.
17   Q    Is this -- the orders at the top of the
18   page, were they written at the same time or
19   two separate occasions, or can you tell?
20   A    I don't recall.  Actually, I do.  I
21   ordered the VQ scan on labor and delivery at
22   10:35, and the heparin, and the PA and
23   lateral chest X-ray, and then the following
24   -- subsequent is when she was transferred to
25   Intensive Care.
0063
 1   Q    So, the first orders were written at
 2   10:35 a.m. on June 26th --
 3   A    Uh-huh.
 4   Q    -- '99 on page 181?
 5   A    Yes.
 6   Q    Could you read those?
 7   A    "VQ scan stat.  Heparin 10,000 unit
 8   bolus, and then 1000 units an hour.  PTT in
 9   six hours."  And then, "follow heparin
10   protocol, PA and lateral chest X-ray."
11   Q    Then, then, apparently, in the
12   Intensive Care Unit you wrote the rest of
13   the orders?
14   A    Yes.
15   Q    Okay.  Could you read the rest of the
16   orders?
17   A    Sure.  "Transfer to ICU.  Dr. Wolfson
18   on consultation.  Diagnosis pre-eclampsia.
19   Rule out pulmonary embolism.  Rule out
20   sepsis.  Condition serious.  Vitals per
21   protocol.  Diet npo, activity bed rest.
22   Nursing Is&Os.   Daily weight.  Foley to
23   continuous gravity, and O/2 via mask.  Labs
24   CBC, magnesium, SGOT, SGPT, PTT Q six
25   hours."
0064
 1   Q    And then you countersigned those orders?
 2   A    Uh-huh.
 3   Q    Is that correct?
 4   A    Yes.
 5   Q    Okay.  Then, why don't you take the
 6   complete chart which -- the complete chart
 7   over here, Exhibit 4.  You also indicated
 8   you authorized the writing of -- first of
 9   all, an order on page 184, and is that the
10   order at the top of the page?
11   A    Yes.
12   Q    Could you read that, please?
13   A    "Dr. Desai called for possible
14   Swan-Ganz catheter placement and fluid
15   management."
16   Q    And what's the time of this order?
17   A    It looks like 1410.
18   Q    2:10 in the afternoon?
19   A    Yes.
20   Q    Okay.  Then, you wrote another order on
21   page 185; is that correct?
22   A    Yes.   "1650, transferred to Medical
23   Intensive Care Unit, University Hospitals."
24   Q    Okay.  Then, that completes all the
25   orders that either you authorized to write
0065
 1   or you wrote yourself?
 2   A    Uh-huh.
 3   Q    Is that correct?
 4   A    Yes.
 5   Q    Okay.  Then, the -- the last item that
 6   -- that appears in these records is the
 7   Discharge Summary report found on pages
 8   three, four and five.  Now, let me ask you
 9   some questions about the Discharge Summary
10   report.
11   A    Uh-huh.
12   Q    First of all, turning to page five, at
13   the bottom of the page, you dictated this
14   report on July 1st, 1999?
15   A    That's correct.
16   Q    Okay, and did you dictate this report
17   before or after you received the results of
18   the autopsy?
19   A    The autopsy results were not available
20   until, I believe, September or October.  It
21   was very late.  So, it was well before.
22   Q    Okay.  When you dictated your Discharge
23   Summary report, you were aware,
24   unfortunately, the patient had died.
25   A    Uh-huh.
0066
 1   Q    Is that correct?
 2   A    Yes.
 3   Q    Then, also on page five, we have a
 4   typewritten, your name, and your signature.
 5   A    Yes.
 6   Q    Does -- does your signature indicate
 7   that you reviewed the contents of three,
 8   four and five, and you approved what's
 9   contained on pages three, four and five?
10             MR. BONEZZI:   Objection to the
11   form of the question.  Go ahead and answer.
12             THE WITNESS:   I read the -- read
13   the summary, yes, and signed it.
14   BY MR. GORDON:
15   Q    Okay, and, therefore, you approved what
16   -- what you dictated.
17   A    Yes.
18   Q    And if you didn't approve that, you
19   could have obviously changed --
20   A    Uh-huh.
21   Q    -- the Discharge Summary report; is
22   that correct?
23   A    Yes.
24   Q    Or if -- if you felt it was necessary,
25   you could have prepared an addendum?
0067
 1   A    Uh-huh.
 2   Q    Is that correct?
 3   A    Yes.
 4   Q    So, you reviewed, before you signed it,
 5   the Discharge Summary report.  You thought
 6   it was accurate, and then you signed it.
 7   A    Uh-huh.
 8             MR. BONEZZI:   Objection.  You
 9   already answered that question.
10   BY MR. GORDON:
11   Q    Now, going to page three at the top of
12   the page, there's number four, "toxic shock
13   syndrome."  It's handwritten.
14   A    Uh-huh.
15   Q    When was that written in?
16   A    That would have been entered at the
17   time I signed the document when I made the
18   other edits in the -- in the document.
19   Q    Okay.  You -- you would have received
20   that information from University Hospitals
21   of Cleveland?
22   A    That she had toxic shock syndrome?
23   That was our working diagnosis when she was
24   transferred to University Hospitals.
25   Q    Okay.  Now, have you reviewed your
0068
 1   Discharge Summary report since the time you
 2   dictated it and signed it?
 3   A    No.
 4   Q    Up until -- did you review it in
 5   conjunction with preparation for your
 6   deposition today?
 7   A    No.  I primarily relied on the nursing
 8   notes.
 9   Q    All right, because I'm going to go over
10   --
11   A    Uh-huh.
12   Q    -- with you the Discharge Summary
13   report and relate it to what's reported in
14   the nurses' notes, et cetera.
15   A    Uh-huh.
16   Q    Okay.  Did you dictate the Discharge
17   Summary report by yourself?
18   A    Yes.
19   Q    What materials did you -- did you use,
20   if any, in dictating the Discharge Summary
21   report?
22   A    The patient's chart.
23   Q    And also what you recall from your own
24   memory?
25   A    Uh-huh.
0069
 1   Q    Is that correct?
 2   A    Yes, at the time.
 3   Q    Just one second.
 4             MR. BONEZZI:   Do you need to
 5   take a break or anything?
 6             THE WITNESS:   I'm okay.
 7             MR. PARIS:     Let's go off the
 8   record.
 9             THE VIDEOGRAPHER:   Off the
10   record.
11             (At this time a short recess was
12   had.)
13             THE VIDEOGRAPHER:   Back on the
14   record.
15   BY MR. GORDON:
16   Q    Okay.  Have you, Dr. Hahn, had an
17   opportunity to read the Discharge Summary
18   report?
19   A    Yes.
20   Q    Okay.  Do you find any inaccuracies in
21   that report, just generally?
22   A    No.
23   Q    That --
24   A    The times that I gave were -- of phone
25   calls may not have corresponded to the
0070
 1   nurses' notes.  I realize that now, in terms
 2   of when there were phone calls, there may be
 3   some discrepancy in those things.
 4   Q    Okay.  Then, in terms of the accuracy
 5   of when the -- those phone calls took place
 6   --
 7   A    Uh-huh.
 8   Q    -- you would defer to what's in the
 9   nurses' notes?
10   A    The nurses' notes, yes.
11   Q    Is that correct?
12   A    Yes.
13   Q    Okay.  Now, the first time you got
14   involved in the care of Mary Williams was on
15   June 25th, 1999 around 3:50 p.m.; is that
16   correct?
17   A    I was not -- I was actually not
18   responsible for her care until I was signed
19   out to in the evening by Dr. Shagawat.  The
20   orders reflect that I gave an order for a
21   type and screen and Rhogam to be
22   administered, but actually the -- my
23   assumption of her care for the evening began
24   when Dr. Shagawat signed out to me, which
25   was after her visit with -- with Ms.
0071
 1   Williams.
 2   Q    Okay.  The question was a little
 3   different.  I thank you for explaining what
 4   you've just told me.  Let me delve that into
 5   a little bit.  You were on call beginning at
 6   what time?
 7   A    Usually around 5:00.
 8   Q    Okay.  That means for whatever patients
 9   of the group that needed attending, you
10   would be the doctor who would be contacted
11   by any medical care provider; is that
12   correct?
13   A    That is correct.
14   Q    All right.  Notwithstanding that, you
15   were -- you -- you took a call from Parma
16   Community General Hospital earlier than five
17   p.m. --
18   A    Uh-huh.
19   Q    -- on June 25th; is that correct?
20   A    That's correct, uh-huh.
21   Q    And you took that call sometime around
22   3:50 p.m. on June 25th; is that correct?
23   A    I have to see the nurses' notes to know.
24   Q    The nurses' notes are found on page
25   160.
0072
 1   A    Uh-huh.
 2   Q    And on the left-hand side.
 3   A    Okay.
 4   Q    At the top of the page.
 5   A    Uh-huh.
 6   Q    It's 1605.
 7   A    Yes, uh-huh.
 8   Q    Okay.  According to your -- let me go
 9   to your Discharge Summary note.
10   A    Uh-huh.
11   Q    It says, "At 3:50 in the afternoon, the
12   patient had an episode of shaking.  There
13   was concern there might have been some
14   seizure activity.  She was seen by the house
15   physician.  She was noted to have good
16   reflexes.  Her urine output was one plus.
17   Urine output was over 100 ccs an hour.  Her
18   previous serum magnesium was 6.1.  The house
19   physician saw her, did not feel it was a
20   seizure activity, and repeat labs were
21   ordered for five p.m."
22             Am I reading that right?
23   A    Actually, no.
24   Q    What am I missing?
25   A    You -- you -- do you want me to reread
0073
 1   the --
 2   Q    No, what did I overlook or --
 3   A    You stated that her urine output was
 4   one plus.  It's actually urine protein.
 5   Q    Urine protein, okay.
 6   A    And you stated, let's see here;
 7   magnesium, you said 6.1, and actually the
 8   document reads 6.6.
 9   Q    Okay.  Other than that, I've read it
10   correctly?
11   A    Yes.
12   Q    Okay, and -- and that's what occurred
13   at 3:50 p.m.?
14   A    Yes.
15   Q    Or thereabouts?
16   A    Yes, uh-huh.
17   Q    Okay.  Now, at that time, you had a
18   conversation with Dr. Hsieh?
19   A    Uh-huh.
20             MR. BONEZZI:   You have to say
21   "yes."
22             THE WITNESS:   Yes.
23   BY MR. GORDON:
24   Q    Okay.  How did that come about at 3:50
25   p.m. or thereabouts?
0074
 1   A    I'm not certain I understand.
 2   Q    How did it come about that you talked
 3   to Dr. Hsieh, according to the nurses'
 4   notes, at 4:05 p.m.?
 5   A    He evidently called the office to speak
 6   with one of the physicians there, and I must
 7   have been the one who was available to take
 8   the call at the time.
 9   Q    Okay.  What did Dr. Hsieh say to you at
10   that time?
11   A    I don't recall the -- the specifics of
12   the conversation.  I mean, I have a general
13   sense of the conversation.
14   Q    Okay.  Could you please give me the
15   general sense of it?
16   A    He stated that he had been called to
17   the room to see the patient because that she
18   was -- appeared to be shivering, and the
19   nursing staff was concerned about that, and
20   the patient had pre-eclampsia, so obviously
21   one of the things you're concerned about is
22   a complication of eclampsia, and he felt,
23   based on his assessment of the patient at
24   the time, that that is not indeed what
25   happened.
0075
 1   Q    Okay.  That's what he told you?
 2   A    Uh-huh.
 3   Q    Is that correct?
 4   A    Yes.
 5   Q    Did Dr. Hsieh give you any other
 6   information such as vital signs, lab values?
 7   A    Again, generally I recall that her
 8   vital signs were stable.  I inquired what
 9   her most recent magnesium level was, and it
10   was therapeutic, and I believe we decided to
11   draw her labs a little sooner to confirm
12   that, in fact, they hadn't changed over the
13   last four or five hours.
14   Q    Do you remember what else was discussed
15   with Dr. Hsieh at that time?
16   A    I don't recall any other.
17   Q    What was your impression --
18   A    Uh-huh.
19   Q    -- or diagnosis at that time?
20   A    We didn't have a diagnosis.  There was
21   a sign of the patient having some shivering.
22   Q    And what did you at that time
23   attribute the shivering to?
24   A    It could be a number of different
25   things.
0076
 1             MR. BONEZZI:   Now, what he --
 2   what he asked was:  what did you attribute
 3   the shivering to?
 4             THE WITNESS:   Okay.  It's very
 5   common for women to shiver after they've
 6   given birth, and I attributed it to that.
 7   BY MR. GORDON:
 8   Q    And what is the cause of the shivering
 9   after birth?
10   A    No one really knows.
11   Q    Okay.  Is there something different
12   between shivering and shaking, or is that
13   the same thing in your mind?
14   A    I -- I --
15             MR. BONEZZI:   Objection.
16             THE WITNESS:   Can you rephrase --
17   rephrase that?
18   BY MR. GORDON:
19   Q    Is there any difference between
20   shivering or shaking in this setting?
21   A    No.  I mean, they'd be the same.  I
22   mean --
23             MR. BONEZZI:   He's asking -- he's
24   asking you to provide an interpretation of
25   those two words that have been written by
0077
 1   somebody else.  So, if you can do that, go
 2   ahead and do that.
 3             THE WITNESS:   I really can't.  I
 4   didn't observe it directly, so I can't.
 5   BY MR. GORDON:
 6   Q    If you were told that, instead of
 7   shivering, there was shaking, would you have
 8   done anything differently at around 3:50
 9   p.m.?
10   A    I would not -- I wouldn't base a
11   decision on the term, shaking.  I would
12   inquire further.
13   Q    And what inquiry would you make, then?
14   A    Was the patient ictal?  Did she appear
15   --
16   Q    Was what?
17   A    Ictal.  I-C-T-A-L.
18   Q    What does that mean?
19   A    Did she appear to have had a seizure?
20   Did she have a loss of consciousness, loss
21   of sensorium?
22   Q    Anything else?
23   A    (At this time the witness shook his
24   head.)
25   Q    Anything  --
0078
 1   A    No.
 2   Q    Okay.  Could you turn to page 188?
 3   A    Uh-huh.
 4   Q    All right.  At the top of the page, do
 5   you recognize Dr. Hsieh's progress note?
 6   A    Uh-huh.
 7   Q    At 1550 p.m.?
 8   A    Yes.
 9   Q    Do you see that?
10   A    Uh-huh.
11   Q    Is that correct?
12   A    Yes.
13   Q    Okay.  In his note, he said the patient
14   appeared shaking, and he reported that to
15   you?
16   A    Yes.
17   Q    "And disappeared shortly."  Did he
18   report that to you?
19   A    Uh-huh.
20   Q    You have to, please --
21   A    Yes.
22   Q    Okay.  He indicates a blood pressure of
23   95 over 78.  Did Dr. Hsieh report that to
24   you?
25   A    I do not receive -- remember receiving
0079
 1   that blood pressure reading of that low.
 2   Q    Okay.  Then, let's -- let's stop there
 3   for a minute.
 4   A    Uh-huh.
 5   Q    Generally speaking, what is a normal
 6   blood pressure for a nonpregnant woman?
 7   A    A nonpregnant woman?
 8   Q    Yes.
 9   A    We can have anywhere from 120 to 140
10   over 70 to 90.
11   Q    Okay.  Then, what is the normal blood
12   pressure of a woman who is within 24 hours
13   of the delivery?
14             MR. BONEZZI:   Objection to the
15   form.  Go ahead and answer.
16             THE WITNESS:   A normal pregnancy,
17   uncomplicated?  There would be a wide range
18   of values for that.  You could have blood
19   pressures as low as 85 over 40 to as high as
20   140 over 90 depending on the patient's state
21   of being, if they're in a great deal of pain
22   or what their pressures have done throughout
23   pregnancy.
24   BY MR. GORDON:
25   Q    All right.  Then, the question is
0080
 1   changed.  A woman who is -- had a diagnosis
 2   of pre-eclampsia before the delivery, what
 3   would be the normal range of such a lady
 4   post-delivery within the 24 hours after
 5   delivery?
 6             MR. BONEZZI:   Objection.  Go
 7   ahead and answer.
 8             THE WITNESS:   That also would be
 9   highly variable depending on how quickly
10   she's recovering from pre-eclampsia.  You
11   could see blood pressures in a very
12   dangerous range, as high as, you know,
13   really 200, 220 over 160, to as low as a
14   normal tensive, postpartum patient who
15   appeared normal.  I mean, you could have
16   blood pressures as low as 80 over 50, 90
17   over 60.  Those would be more unusual.
18   Q    The 80 over 50 or the 90 over 60?
19   A    Uh-huh.
20   Q    Is that correct?
21   A    Yes.
22   Q    Okay.  Okay.  With respect to the 95
23   over 78 --
24   A    Uh-huh.
25   Q    -- was that -- would that be abnormal
0081
 1   for this type of patient, "this" being
 2   post-delivery --
 3   A    Uh-huh.
 4   Q    -- diagnosis of pre-eclampsia before
 5   the delivery.
 6   A    That's hard to say too.  It's an
 7   isolated blood pressure reading, usually
 8   taken with an automatic blood pressure cuff,
 9   so I would not base management on a single
10   reading.  I would base my management on a
11   series of readings around that time.
12   Q    Okay.  Is it your testimony today that
13   you were not told by Dr. Hsieh of the blood
14   pressure of 95 over 78?
15   A    That's correct.
16             MR. BONEZZI:   Objection.  Go
17   ahead and answer.
18             THE WITNESS:   Yes, that's
19   correct.
20   BY MR. GORDON:
21   Q    Okay.  If you had been told of the
22   blood pressure of 95 over 78 --
23   A    Uh-huh.
24   Q    -- hypothetically, what would you have
25   done?
0082
 1   A    Uh-huh, seen what the next series of
 2   blood pressures were.
 3   Q    And how would you have done that?
 4   A    They're done automatically.  These
 5   patients that are pre-eclamptic often have
 6   an automatic blood pressure cuff on that
 7   cycles at a certain interval.
 8   Q    Okay.  So, you would have, am I
 9   correct, asked for blood pressures for a
10   certain time frame?
11   A    Uh-huh.
12   Q    Am I correct?
13   A    Yes.
14   Q    What time frame?
15   A    To see what -- over the next half hour,
16   to see what the range is.
17   Q    You would?
18   A    Right, to see what this patient is
19   doing.
20   Q    And why would you want to do that?
21   What's the purpose in doing that?
22   A    Well, the purpose would be to look, you
23   know, does the patient have something else
24   going on here?  Is she -- is she bleeding
25   internally?  If the patient's blood pressure
0083
 1   is dropping, it would be a very -- you know,
 2   sometimes you'd want to look for.
 3   Q    Then, at least can we agree that, if
 4   you had been told of the blood pressure of
 5   95 over 78 at 1550 p.m., you would have at
 6   least been concerned about that?
 7   A    Uh-huh, or --
 8             MR. SCHOBERT:  Objection.
 9             THE WITNESS:   Wanting to follow
10   it further.
11   BY MR. GORDON:
12   Q    Okay.  Were you told by Dr. Hsieh the
13   heart rate of 82?
14   A    I -- I don't recall that.  I mean, the
15   nature of the conversation that I recall was
16   that this patient is a stable patient.  Her
17   vital signs are stable.  She has a good
18   urine output, and it was not his impression
19   that she had an eclamptic seizure.
20   Q    Okay.  With the statement, vital signs
21   stable --
22   A    Uh-huh.
23   Q    -- is that inconsistent with a blood
24   pressure of 95 over 78?
25             MR. BONEZZI:   Objection.
0084
 1             MR. SCHOBERT:  Objection.
 2             THE WITNESS:   As I previously
 3   stated, I wouldn't base a treatment on a
 4   single blood pressure.  So, I can't state
 5   whether this patient is stable or not with a
 6   single measurement.
 7   Q    Okay, you would be --
 8   A    Further measurement.
 9   Q    Okay.  Now, with respect to the --
10   let's stop here for the heart rate.  Let's
11   go back, okay?  Heart -- what is the normal
12   heart rate for a nonpregnant woman, the
13   range?
14   A    Seventy-two to 95.
15   Q    Then, the normal range for a woman
16   post-delivery with -- within the first 24
17   hours after delivery, and we're talking
18   about the heart rate now --
19   A    Uh-huh.  It would be anywhere --
20   usually the pulse is somewhat elevated, so
21   80 to 110.
22   Q    Okay.  Now, with Mary Williams'
23   situation in which she was diagnosed as
24   pre-eclampsia before the delivery, what
25   would be the normal heart rate within 24
0085
 1   hours after the delivery for this type of
 2   patient?
 3   A    Uh-huh.  It would be the same.
 4   Q    Eighty to --
 5   A    Uh-huh.
 6   Q    -- 110?
 7   A    Uh-huh.
 8             MR. BONEZZI:   Yes?
 9             THE WITNESS:   Yes.
10   BY MR. GORDON:
11   Q    Okay.  Were you provided any -- strike
12   that.
13             Were you -- were you told about
14   the deep tendon reflexes plus two?
15   A    Yes.
16   Q    The urine protein, is that --
17   A    Plus one.  I -- I -- again, I don't
18   recall the specifics of what he told me.  I
19   don't recall if he told me, you know, his --
20   his assessment was that she had, you know,
21   active reflexes, and I don't recall that he
22   told me what her protein status was, and
23   frankly that's sort of irrelevant to the --
24   her -- the situation, other than it -- it
25   confirms the diagnosis of pre-eclampsia
0086
 1   which we've already pre-established.
 2   Q    Then, were you told about the urine
 3   output of 100 ccs an hour?
 4   A    Yes.
 5   Q    And what is the normal urine output for
 6   a woman post-delivery within the first 24
 7   hours?
 8   A    I don't think we're discussing normal
 9   range.  There's an accepted range of
10   oliguria where urine output is decreased,
11   and that -- that would be less than 30 ccs
12   per hour.
13   Q    Okay.  Would -- would that definition
14   of oliguria apply also to a patient who had
15   been previously diagnosed with
16   pre-eclampsia?
17   A    Yes.
18   Q    All right.  Then, there's -- a serum
19   magnesium on June 25th, '99 at 11 a.m. was
20   6.6.  So, this is Dr. Hsieh's note.  Were
21   you told of the serum magnesium levels?
22   A    I was told that it was therapeutic.
23   Q    Okay.  What's the purpose of giving
24   serum magnesium to a patient such as Mary
25   Williams?
0087
 1   A    To prevent seizures.
 2   Q    And is there a certain range that you,
 3   as a physician who orders serum magnesium,
 4   attempts to obtain to keep the serum
 5   magnesium in a therapeutic level?
 6   A    Uh-huh.
 7   Q    And that -- that answer is yes?
 8   A    Yes.
 9   Q    And what is that range?
10   A    Between four and eight.
11   Q    And then there's a certain level above
12   eight that you have adverse effects from the
13   serum magnesium?
14   A    Yes.
15   Q    And what adverse effects?
16   A    Ultimately, respiratory depression.
17   Q    Okay, but, basically, the serum
18   magnesium is to prevent seizures.
19   A    Correct.
20   Q    Okay, and how long is that normally
21   given to a patient with a diagnosis of
22   pre-eclampsia post-delivery?
23   A    Twenty-four hours.
24   Q    And is it then the 24 hours then the
25   highest -- strike that.
0088
 1             The 24 hours then is the period of
 2   highest risk for seizures --
 3   A    Correct.
 4   Q    -- with a patient who had
 5   pre-eclampsia?
 6   A    That's correct.
 7   Q    And, then, you talk about the
 8   magnesium, two grams IV an hour.  That was
 9   being given to the patient?
10   A    That is correct, sir.
11   Q    Okay, and, then, we turn to the orders
12   which are found on page 179, and, then, the
13   order of 1550 is "repeat the serum magnesium
14   at seven p.m."?
15   A    Yes.
16   Q    Let me -- let me --
17   A    That's 17.
18             MR. BONEZZI:   That's 17.
19   BY MR. GORDON:
20   Q    Let me just -- at 1700 it should be.
21   1700 p.m.; is that correct?
22   A    Yes.
23   Q    Or 5:00, and why was -- why was a
24   repeat serum magnesium ordered?
25   A    Actually, that order is not a -- a new
0089
 1   order.  If you review the previous orders,
 2   the -- the magnesium was ordered for every
 3   six hours.  So, I'm not certain why Dr.
 4   Hsieh made that entry into the chart.
 5   Q    Okay.
 6   A    But her previous magnesium was at 11
 7   a.m., and the subsequent would have been at
 8   1700.
 9   Q    Okay, and the CBC was ordered as well.
10   A    That also had been a standing order by
11   Dr. Shagawat from the morning.
12   Q    Okay.  The question is:  did you tell
13   Dr. Hsieh to order a CBC?
14   A    I don't recall, but it was a standing
15   -- I mean, I probably -- I asked him when
16   the next set of labs were to be done --
17   Q    Okay.
18   A    -- which would have been at 1700.
19   Q    Would it be more likely than not that
20   you ordered -- asked -- strike that.
21             Would it be more likely than not
22   that you asked Dr. Hsieh to order a complete
23   blood count?
24             MR. BONEZZI:   Objection.  That's
25   not what he said.
0090
 1             THE WITNESS:   I -- as I stated,
 2   he -- it was already -- I inquired when her
 3   next set of labs would be due or when they
 4   were planned based on standing orders from
 5   Dr. Shagawat, and that he told me that would
 6   be at seven -- or 1700, 5:00.
 7   BY MR. GORDON:
 8   Q    Then, what instructions, if any, did
 9   you give to Dr. Hsieh --
10   A    Uh-huh.
11   Q    -- regarding this patient after you had
12   this discussion with him?
13   A    That I felt that, based on his
14   assessment, that we should just continue to
15   observe her.
16   Q    Continue to observe her.
17   A    Right.
18   Q    Anything else?
19   A    No.
20   Q    And then did you give him any
21   parameters, time frame of how long she
22   should be -- that she should be observed?
23   A    Well, a patient who is on magnesium is
24   -- I wouldn't have made a stipulation to
25   that.
0091
 1   Q    Yeah.
 2   A    Because a patient who's on magnesium is
 3   -- basically has one-to-one nursing.  So,
 4   she is by definition under an extended state
 5   of close observation.
 6   Q    So, how did you leave it with Dr.
 7   Hsieh?
 8             MR. BONEZZI:   Objection.
 9   BY MR. GORDON:
10   Q    You had your discussion with him, and
11   then what?  Just continue to observe?
12             MR. BONEZZI:   Don't answer.  He
13   already told you that.
14             MR. GORDON:    No, no.
15             MR. BONEZZI:   No.  You just asked
16   him that, Harley, and he said he told Dr.
17   Hsieh to continue to observe, and then he
18   explained to you --
19             MR. GORDON:   I understand that, I
20   just --
21             MR. BONEZZI:   -- the whole thing.
22   BY MR. GORDON:
23   Q    Did you give him any instructions to
24   call you back or anything of that sort?
25             MR. BONEZZI:   Objection.  Go
0092
 1   ahead and answer.
 2             THE WITNESS:   No.
 3   BY MR. GORDON:
 4   Q    Okay.  Then -- then, chronologically,
 5   at around five p.m., you were on call.
 6   A    Uh-huh.
 7   Q    Is that correct?
 8   A    Yes.
 9   Q    Then, after five p.m., you did receive
10   a call regarding Mary Williams.
11   A    Late -- well, my partner who was in the
12   office was going to see her as well after we
13   finished office hours, and she did, and it's
14   documented at 5:30.
15   Q    Okay.
16   A    And I believe she called me to tell me
17   that everything looked stable with the
18   patient.
19   Q    Is that -- okay.  So, Dr. Shagawat
20   called you some time after -- let's say the
21   time the note was written at 1730 or 5:30
22   p.m.?
23   A    Uh-huh.
24   Q    Is that correct?
25   A    Yeah.
0093
 1   Q    Okay, and did she tell you that the
 2   patient was groggy, tired, had blurry vision?
 3   A    I don't recall honestly the nature of
 4   the conversation except I was left with the
 5   impression that the patient was stable.
 6   Q    Specifically, were you told by Dr.
 7   Shagawat the blood pressure of 154 over 89?
 8   A    Again, I don't recall the specific
 9   content of the conversation, just that my
10   impression was that her impression was that
11   Mary was proceeding normally.
12   Q    Would you -- were you advised of the
13   temperature of 99.7?
14   A    No.
15   Q    Now, let's talk about temperature,
16   okay?
17   A    Uh-huh.
18   Q    I have a conversion chart from
19   Fahrenheit to Centigrade.
20   A    Uh-huh.
21   Q    99.7 is 37.6 degrees -- strike that.
22   99.7 degrees Fahrenheit is 37.6 degrees
23   Centigrade; is that correct?
24   A    Yes.
25   Q    Okay.  Now, now, let's talk about
0094
 1   temperature, and normal temperature in a
 2   nonpregnant woman is what?
 3   A    Thirty-seven degrees.
 4             MR. JEFFERS:   I couldn't hear
 5   you.
 6             THE WITNESS:   Thirty-seven
 7   degrees Centigrade, 98.6 degrees Fahrenheit.
 8   BY MR. GORDON:
 9   Q    Okay.  Then, you have a woman
10   post-delivery within the first 24 hours.
11   What is the normal temperature, normal
12   temperature range?
13   A    There's -- I think the question is sort
14   of --
15             MR. BONEZZI:   Go ahead.
16             THE WITNESS:   What you really
17   want to phrase is, there's not an accepted
18   temperature range, nor is there an accepted
19   -- a definition of fever in the first 24
20   hours.  There's -- there's not a definition
21   for fever in the first 24 hours after a
22   delivery.
23   BY MR. GORDON:
24   Q    First of all, can you refer me to any
25   literature that says -- which says that,
0095
 1   within 24 hours after labor and delivery,
 2   after -- after -- strike that.
 3             Within 24 hours after the
 4   delivery, there's no definition of fever
 5   according to any medical literature?
 6   A    Well, puerperal fever excludes a
 7   temperature -- an elevation in the first 24
 8   hours.
 9   Q    An elevation?
10   A    Correct.
11   Q    Is that what you said?
12   A    Yes.
13   Q    Okay.  So, how, then, do you determine,
14   you as an obstetrician --
15   A    Uh-huh.
16   Q    -- what is really a fever in a patient
17   --
18   A    Uh-huh.
19   Q    -- or just a temperature elevation
20   within the first 24 hours after delivery?
21   A    You look at the patient.  I look at
22   risk factors.   The assessment of the people
23   who are there with the patient, what are
24   their risk factors for their delivery, to
25   discern whether or not they could have a
0096
 1   potential infection or not, but a
 2   temperature elevation is very common in the
 3   first 24 hours following a delivery.
 4   Q    And, then, what is common within the
 5   temperature elevation within the first 24
 6   hours?  There's no range at all?
 7   A    Correct.
 8   Q    It could be -- it could be beyond 38
 9   degrees Centigrade within the first 24
10   hours, and that wouldn't concern you?
11             MR. BONEZZI:   Objection.  That's
12   not what he said.  Go ahead and answer.
13   BY MR. GORDON:
14   Q    Or would it?
15   A    It would depend on the patient and the
16   clinical circumstances.
17   Q    Okay.  So, if you had a patient -- a
18   patient who did have a fever of 38 degrees
19   Centigrade within 24 hours after delivery,
20   it depends upon the circumstances --
21   A    Uh-huh.
22   Q    -- whether or not you felt that was
23   just a temperature -- temperature elevation
24   or a fever?
25   A    Correct.
0097
 1   Q    Okay.  What -- what fact -- what risk
 2   factors would you be looking to?
 3   A    Mode of delivery; length of rupture of
 4   membranes prior to delivery; socioeconomic
 5   status is part of those risk factors;
 6   results of patient's screen for Group B
 7   streptococcus; the degree of
 8   instrumentation; or numbers of exams with
 9   delivery.
10   Q    Have you finished your risk factors?
11   A    Uh-huh.
12   Q    Okay.  So, a -- am I correct you
13   finished your risk factors?
14   A    Yes.
15   Q    Okay.  So, the mode of delivery, so
16   you'd be looking at whether it's a vaginal
17   or Cesarean; is that correct?
18   A    That's correct.
19   Q    And if it was -- you'd be more
20   concerned if it was a Cesarean rather than a
21   vaginal --
22   A    That's correct.
23   Q    -- with a temperature elevation?
24   A    Yes, yes.
25   Q    The -- the time of rupture of membranes
0098
 1   would be a certain time frame --
 2   A    Uh-huh.
 3   Q    -- would -- which -- after which you
 4   would be concerned.  What -- what would be
 5   the time frame?
 6   A    Someone who was ruptured more than 12
 7   hours prior to delivery would be more at
 8   risk for infection.
 9   Q    Why?
10   A    There's a greater chance of bacteria
11   ascending from the vagina into the uterus
12   with the length of time.
13   Q    Okay.  When you talk about
14   instrumentation --
15   A    Uh-huh.
16   Q    Are you -- what -- what would that --
17   what does that refer to?
18   A    If internal monitors were used such as
19   an intrauterine pressure scalpel or scalp
20   electrode.
21   Q    Vacuum extraction, would that --
22   A    That could, or forceps.
23   Q    Okay.
24   A    Although those don't go up into the
25   uterine cavity like internal monitors do.
0099
 1   Q    Okay, then the other thing you talk
 2   about, the assessment of the patient, would
 3   -- would impact upon your decision as to
 4   whether or not the temperature elevation is
 5   just a fever, normal fever --
 6   A    Uh-huh.
 7   Q    -- after the delivery or portends an
 8   infection?
 9   A    Uh-huh.
10   Q    What would that assessment consist of?
11   A    Physical examination.
12   Q    How about lab values?
13   A    In the puerperal period, lab values are
14   -- are going -- you're not going to be able
15   to interpret a white count in the first 24
16   hours.  It's going to be elevated regardless
17   of whether there's an infection there or
18   not.
19   Q    Going back to, what then does cause a
20   temperature elevation within the 24 hours
21   after delivery?
22   A    There could be a number of factors:
23   atelectasis, which is a decrease in the --
24   the expansion of the lung.  The basis of the
25   lungs will sort of collapse, if you will,
0100
 1   and that could be due to postpartum pain.
 2   The patient may not breathe as deeply
 3   because of discomfort.  There's a lot of
 4   tissue necrosis from delivery, and those
 5   factors can cause fever as well.  Later in
 6   the course of delivery, breast engorgement
 7   can cause fever.
 8   Q    Now, you also mentioned about the
 9   assessment.  Are you talking about the
10   physical exam?  What specifics of the
11   physical exam --
12   A    Uh-huh.
13   Q    -- would you like to know --
14   A    Uh-huh.
15   Q    -- in terms of determining whether it's
16   a fever from the natural course of the
17   delivery versus an infection?
18   A    Uh-huh.  Abdominal exam, is the -- the
19   fundus of the uterus tender, or is the
20   patient experiencing abdominal tenderness?
21   Is there foul-smelling lochia or a foul
22   discharge from the vagina, increasing
23   peritoneal pain in the episiotomy?
24   Q    Now, is that it?
25   A    Uh-huh.
0101
 1   Q    Am I correct?
 2   A    Yes.
 3   Q    Okay, and, then, you mentioned about
 4   lab values, and you say they -- they have no
 5   consequence at all in helping you as a
 6   physician determine whether -- if you do
 7   have an elevated temperature, whether it's a
 8   fever from the natural course of the
 9   delivery or -- or an infection?
10   A    It's -- they're difficult to interpret
11   because you're going to have an elevated
12   white blood cell count after delivery in --
13   in the face of infection or in the absence
14   of infection.
15   Q    Okay.  When you -- what causes an
16   elevated white blood count then from the
17   delivery process?
18   A    We're not sure.  We think it's
19   demargination where white cells that are
20   adherent to the blood vessels demarginate
21   and go into -- or are then present in the
22   bloodstream for measurement, and there are a
23   lot of acute phase reactants that happen
24   with labor, prostaglandins and a lot of
25   biochemical mediators that are involved in
0102
 1   the labor process that cause your immune
 2   system to respond.
 3   Q    Okay.  Now, with respect to the white
 4   blood count --
 5   A    Uh-huh.
 6   Q    -- okay, first of all, do you know what
 7   bandemia is?
 8   A    Yes.
 9   Q    What's bandemia?
10   A    Well, bandemia refers to a presence of
11   more than ten percent bands in a white
12   count.
13   Q    Okay.  If you have a white blood count
14   which is elevated but -- but you do have
15   bandemia--
16   A    Uh-huh.
17   Q    -- does that assist you in determining
18   whether or not elevated temperature is from
19   the natural course of the delivery or from
20   an infection?
21   A    Many of the -- no, because many
22   patients will have a bandemia in an
23   uninfected vaginal delivery as well.
24   Q    From what?
25   A    An uninfected vaginal delivery, they'll
0103
 1   have a bandemia as well.
 2   Q    And what causes the bandemia?
 3   A    The same thing.  It's the immature
 4   white cells.
 5   Q    And that process again is the
 6   demarginization you're talking about?
 7   A    Uh-huh.
 8   Q    Is that correct?
 9   A    Right, and your -- the biochemical
10   mediators with labor, they -- they enhance
11   your immune system, and as a result, you --
12   you produce and release more immature white
13   cells into your bloodstream.
14   Q    Could you tell me what a left shift is?
15   A    It's the same thing.  When you see an
16   increase in immature white blood cell forms,
17   one of the most -- the band being the most
18   common.
19   Q    It's what?
20   A    Bands are the immature white cell that
21   you see with the left shift.
22   Q    Okay.  So, with respect to the left
23   shift, you're saying, if you have a left
24   shift --
25   A    Uh-huh.
0104
 1   Q    -- in a patient with an elevated
 2   temperature --
 3   A    Uh-huh.
 4   Q    -- within 24 hours after delivery, that
 5   still doesn't help you in terms of
 6   determining whether it's the fever -- strike
 7   that; in determining whether the elevated
 8   temperature is from the delivery process or
 9   from an infection?
10   A    That's correct.
11   Q    And can you refer me to any source that
12   says that?
13   A    That's the standard of care and
14   knowledge.
15   Q    And where is that standard of care
16   written?
17   A    The standard of care is not written in
18   any textbook.  It's a consensus of many
19   sources:  your education, your experience.
20   Q    Have you ever seen that standard of
21   care that we're talking about in any written
22   form regarding --
23   A    Uh-huh.
24   Q    -- that a left -- if there is a left
25   shift, that doesn't help an obstetrician
0105
 1   determine whether the elevated temperature
 2   is from the delivery process itself or is
 3   evidence of an infection?
 4   A    I can't quote you a source, no.
 5   Q    Then, if -- for instance, you would
 6   consider a patient, a normal patient who has
 7   a fever of 38 degrees Centigrade or 100.4
 8   degrees Fahrenheit; is that correct?
 9   A    I'm sorry.  Say that again.
10   Q    In a normal patient --
11   A    Uh-huh.
12   Q    -- without delivery, a fever would be
13   100.4 degrees Fahrenheit, 38 degrees
14   Centigrade.
15   A    You use 38 in a -- in an institution
16   that uses the Centigrade scale.  Most
17   institutions that use the Fahrenheit scale,
18   we use a temperature of 100.5, but again
19   that depends on the clinical scenario and
20   what you're dealing with.
21   Q    But with a normal patient, without even
22   looking at the clinical scenario --
23   A    Uh-huh.
24   Q    -- if you had a patient who had a
25   temperature of 38 degrees Centigrade --
0106
 1   A    Uh-huh.
 2   Q    -- without any delivery --
 3   A    Uh-huh.
 4   Q    -- you'd consider that a fever?
 5   A    Yes.
 6   Q    But in -- when you have a patient who
 7   is within 24 hours after delivery --
 8   A    Uh-huh.
 9   Q    -- that principle doesn't apply in
10   terms of 38 degrees Centigrade?
11   A    Correct.
12   Q    Now, why is the time measured from the
13   time of delivery rather than any other time
14   in -- in evaluating an elevated temperature?
15   A    Because the -- the -- in my teaching,
16   the -- the likelihood of infection with a
17   temperature elevation in the first 24 hours
18   is very unlikely, because of all the other
19   causes of -- of temperature elevations.
20   Q    Maybe -- maybe I misunderstood you.
21   Why does the time frame run from the time of
22   delivery for the 24 hours rather than, let's
23   say, from the time of rupture of membranes?
24   A    It's -- because -- our convention has
25   been that, when you get beyond 24 hours, if
0107
 1   you see a fever, infection is a more common
 2   or possible cause of the fever versus the
 3   first 24 hours after delivery.
 4             MR. BONEZZI:   But what he asked
 5   is:  in attempting to set the timing --
 6             THE WITNESS:   Uh-huh.
 7             MR. BONEZZI:   -- when does the
 8   24-hour period of time commence?  Why is it
 9   at the time of delivery as opposed to the
10   time of the rupture of membranes, which may
11   be hours and hours and hours prior to
12   delivery?
13             THE WITNESS:   Uh-huh.
14             MR. BONEZZI:   That's what he
15   wants to know.
16             THE WITNESS:   It's just -- it's
17   by convention.
18   BY MR. GORDON:
19   Q    Okay, but it looks like -- let's go
20   back to the rupture of membranes.  That's
21   also an event that has a potential of
22   introducing bacteria in the vaginal canal.
23             MR. BONEZZI:   Objection.  He said
24   when it's greater than 12 hours.
25   BY MR. GORDON:
0108
 1   Q    When it's greater than -- well, let me
 2   -- then just start over.
 3             Is -- the rupture of membranes,
 4   that event, can it lead in some time frame
 5   to the introduction of bacteria into the
 6   vaginal canal?
 7             MR. BONEZZI:   From the vaginal
 8   canal.
 9   BY MR. GORDON:
10   Q    Yeah.
11   A    From the vaginal canal to the uterine
12   cavity.
13   Q    Right, right.
14   A    Yes, yes.
15   Q    Okay.  There are, however, cases in
16   which a patient does have a temperature of
17   30 degrees Centigrade within 24 hours of the
18   delivery.
19             MR. BONEZZI:   Thirty degrees
20   Centigrade?
21   BY MR. GORDON:
22   Q    I'm sorry.  Let me start -- there are
23   situations in which a patient has a
24   temperature of 38 degrees Centigrade within
25   24 hours from the time of delivery, and the
0109
 1   cause of that temperature is the fact that
 2   there is a uterine infection; am I correct?
 3   A    That can be true in some situations.
 4   Q    Okay.  So, you as an obstetrician keep
 5   that -- you keep that principle in mind.
 6   A    Uh-huh, yes.
 7   Q    Is that correct?
 8   A    Yes.
 9   Q    That you still -- even though you do
10   have a temperature elevation, let's say the
11   38 degrees Centigrade, you still have to
12   make a decision as to whether that
13   temperature is from the natural course of
14   the delivery or maybe a uterine infection?
15   A    Yes.
16             MR. BONEZZI:   Objection.  He's
17   already explained to you that the
18   temperature elevation isolated in that first
19   24-hour period of time does not necessarily
20   mean there is an infection.  However, he
21   takes into consideration the risk factors
22   that are associated with that coupled with
23   the elevation in temperature.  He's
24   explained that to you repeatedly, Harley.
25             MR. GORDON:   He is talking -- I'm
0110
 1   -- I'm more specific about a uterine
 2   infection.
 3             MR. BONEZZI:   Harley, specific
 4   about what; vaginal versus uterine?  We're
 5   talking about a delivery here.
 6             MR. GORDON:    Now --
 7             MR. BONEZZI:   You have to deliver
 8   from the uterus.
 9   BY MR. GORDON:
10   Q    Now, we talked about Dr. Shagawat's
11   progress note, and we left off at the
12   temperature of 99.7, and I want to go on.
13   So, the 99.7 degrees Fahrenheit, in and of
14   itself, would not have concerned you; am I
15   right?
16   A    In this patient, no.
17   Q    At that time.
18   A    Yes, that's correct.
19   Q    And then you had a white blood count of
20   16.1 according to Dr. Shagawat's note.
21   A    Yes.
22   Q    Is that right?  Let's talk about the --
23   the white blood count for a moment.  Okay.
24   Could you turn to page 42 maybe?  This will
25   be a little helpful to us.
0111
 1             Page 42 at 1700, that's 5:00 p.m.,
 2   you have a white blood count of 16.1, and
 3   the normal range is four to 10.8 according
 4   to the lab at Parma Community General
 5   Hospital; is that correct?
 6             MR. BONEZZI:   Objection.  That
 7   norm, you -- you better differentiate
 8   because that norm is for all patients at
 9   Parma Community as opposed to those patients
10   who are under obstetrical care and who have
11   delivered.  So, clarify that, please,
12   because that's a misstatement that you're
13   about to make.
14   BY MR. GORDON:
15   Q    Has Mr. Bonezzi clarified that?
16   A    Yes.
17   Q    Okay.  So, to clear that up, the normal
18   range for, let's say, a nonpregnant woman
19   for white blood count would be four to 10.8?
20   A    Did you -- did you say nonpregnant
21   woman?
22   Q    Yeah.
23   A    That would be correct.
24   Q    Okay. Then, now, with a woman who is
25   pregnant, does the white blood count go up?
0112
 1   A    Yes.
 2   Q    And what is the range?
 3   A    It can be as high as 12 to sometimes
 4   13,000.
 5   Q    Okay, and that's still considered
 6   within normal range?
 7   A    Yes.
 8   Q    Okay.  What is the normal range of a
 9   woman who is within -- of the white blood
10   count --
11   A    Uh-huh.
12   Q    -- who has within 24 hours of the
13   delivery?
14   A    It could go as high as 20, 22,000
15   sometimes.
16   Q    Okay.  We talked earlier about bands.
17   A    Uh-huh.
18   Q    And is there -- with respect to, for
19   instance, a nonpregnant woman, the bands you
20   indicated would be somewhere around ten
21   percent.
22   A    Uh-huh.
23   Q    Right?
24   A    Nonpregnant, normal individual?
25   Q    Right.
0113
 1   A    Yes.
 2   Q    How about during pregnancy?
 3   A    Oh, it stays the same.
 4   Q    Okay, but after delivery within the 24
 5   -- first 24 hours --
 6   A    Uh-huh.
 7   Q    -- it changes?
 8   A    Yes.
 9   Q    And what is the normal range?
10   A    It can go up as high as ten to 15
11   percent.
12   Q    Okay.  Then, with respect to
13   neutrophils --
14   A    Uh-huh.
15   Q    -- the normal range for a nonpregnant
16   woman is 41.5 to 7.5 --
17   A    Seventy-five.
18                  MR. BONEZZI:   Seventy-five.
19   Q    75.5?
20   A    Yes.
21   Q    How about for a pregnant woman?
22   A    It would be the same.
23   Q    And how about for a lady within the
24   first 24 hours after delivery?
25   A    You -- you'll see more of a shift up to
0114
 1   as high as maybe 95 percent.
 2   Q    How about -- okay, and how about, it
 3   looks like -- metamyelocytes, do you know
 4   what those are?
 5   A    Uh-huh.
 6   Q    What are metamyelocytes?
 7   A    They are a more immature form of white
 8   blood cell.
 9   Q    Okay, and these white blood cells, one
10   of the purposes is to go out and fight
11   infection?
12   A    Correct.
13   Q    To fight the bacteria so they don't
14   grow?
15   A    That's correct.
16   Q    And fight the bacteria so they kill the
17   bacteria?
18   A    Correct.
19   Q    So, there's no proliferation of the
20   bacteria?
21   A    Right.
22   Q    Okay.  Now, with respect to
23   metamyelocytes, what's the normal range for
24   a nonpregnant woman?
25   A    Usually one or zero.
0115
 1   Q    What is the normal range of
 2   metamyelocytes for a pregnant woman, a
 3   pregnant --
 4   A    I said one -- I'm sorry.  I thought
 5   your first question was pregnant woman.
 6   Q    Maybe you misunderstood.  Let me
 7   backtrack.  What is the normal range of
 8   metamyeolocytes for a nonpregnant woman?
 9   A    Usually zero to one.
10   Q    What is the normal range for
11   metamyelocytes for a pregnant woman?
12   A    One.
13   Q    What is the normal range for
14   metamyeolocytes for a woman within 24 hours
15   of the delivery?
16   A    You'll -- you'll see a shift.  It may
17   be up as high as three or four
18   metamyelocytes.
19   Q    What causes that in the first 24 hours
20   after the delivery for the metamyelocytes?
21   A    It's the same mechanism as for
22   bandemia.
23   Q    Can you refer me to any literature that
24   says that?
25   A    No.
0116
 1   Q    Okay.  Now, am I -- after your
 2   conversation with Dr. Shagawat --
 3   A    Uh-huh.
 4   Q    -- you then received another call
 5   regarding Mary Williams later in the day.
 6   A    Uh-huh.
 7   Q    Is that correct?
 8   A    Yes.
 9   Q    According to your -- let's go to your
10   Discharge Summary.
11   A    Uh-huh.
12   Q    Okay.  It says, "I received a call
13   later in the day."  Do you know where I am
14   now?
15   A    Yes.
16   Q    I'll start over.  It's close to the
17   bottom of the page.  This is on page three.
18   "I received a call later in the day that the
19   patient spiked a temperature to 100.6 --"
20   That would be degrees Fahrenheit; is that
21   correct?
22   A    That would be correct.
23   Q    "-- at 7:25 p.m."  Is that correct?
24   A    Yes.
25   Q    Okay.  Am I correct that the 100.6
0117
 1   degrees Fahrenheit in your Discharge Summary
 2   is incorrect?
 3   A    It appears in the nurses' notes that
 4   101.6 was the value they recorded, and I --
 5   I don't recall at this late point what I
 6   received or was told on the phone, but,
 7   regardless, it was a temperature -- she had
 8   a mild temperature elevation.
 9   Q    So, you were told over the phone of
10   either a temperature of 100.6 degrees
11   Fahrenheit --
12   A    Uh-huh.
13   Q    -- or 101.6 degrees Fahrenheit; is that
14   correct?
15   A    That is correct, uh-huh.
16   Q    And 100.6 degrees Fahrenheit would be
17   38.1 degrees Centigrade; is that correct?
18   A    That is correct.
19   Q    And 100.6 degrees Fahrenheit would be
20   38.7 degrees --
21   A    101.6.
22             MR. BONEZZI:   101.6.
23   BY MR. GORDON:
24   Q    I am sorry.  I'm looking at -- the
25   temperature of 101.6 degrees Fahrenheit
0118
 1   would be a temperature of 38.7 degrees
 2   Centigrade.
 3   A    You said 101.6 is 38.7?  I would agree,
 4   yes.
 5   Q    Okay.  Well, then, would a temperature
 6   -- strike that.  In either case, a
 7   temperature of 100.6 or 101.6, it still
 8   would be of concern to you --
 9             MR. BONEZZI:   Objection.
10   BY MR. GORDON:
11   Q    -- within the first 24 hours.
12             MR. BONEZZI:   Objection to the
13   term "concern."  Go ahead and answer.
14             THE WITNESS:   It's something to
15   pay attention to.  Again, it's not a -- in
16   the first 24 hours of a low risk delivery.
17   BY MR. GORDON:
18   Q    Okay, and you -- you use the word
19   "spiked."  That means it went --
20   A    Elevation.
21   Q    Okay.  Then, you say in the Discharge
22   Summary, "At that time her pulse and vital
23   signs were stable, as I was informed by the
24   nursing staff, with good urine output."  Is
25   that correct?
0119
 1   A    That's correct.
 2   Q    Then, in that regard, would a blood
 3   pressure of 119 over 53, would that be
 4   considered a stable blood pressure?
 5   A    Yes.
 6   Q    Would a heart rate of 102 be considered
 7   a stable blood pressure?
 8   A    Yes.
 9   Q    I'm sorry, a stable heart rate.
10   A    Yes.
11   Q    Would a respiration rate of 22 be
12   considered a stable respiration rate?
13   A    Yes.
14   Q    Okay.  Now, what's a normal respiration
15   rate for a nonpregnant woman?
16   A    Anywhere from 15 to 20.
17   Q    For -- for a pregnant woman, what is
18   the normal range for a respiration rate?
19   A    Eighteen to 25.
20   Q    And what causes the elevation in
21   respiration rate?
22   A    There -- their titer volume decreases
23   because of the pressure of the pregnancy, so
24   to move the same amount of volume of air
25   through the respiratory system, they have a
0120
 1   compensatory increase in respiratory rate.
 2   Q    And what -- what is a normal range for
 3   a woman within 24 hours after the delivery?
 4   A    Again, it would be the same as
 5   pregnancy, 18 to 25.
 6   Q    Would -- then anything above 25 would
 7   be abnormal?
 8             MR. BONEZZI:   Objection.  Go
 9   ahead and answer.
10             THE WITNESS:   You'd be looking at
11   -- again, you're looking at a single sign.
12   You know, what would be the context?  Does
13   the patient appear short of breath?  I mean,
14   these numbers are -- are -- they are
15   relative normal ranges, but you -- you can't
16   isolate a number and call it normal or
17   abnormal without looking at the context of
18   the whole clinical picture.
19             MR. BONEZZI:   Excuse me.  In that
20   previous question, Harley, did you suggest
21   that the temperature was 101.6 and the heart
22   rate was 102 and the respiration rate was
23   22?
24             MR. GORDON:   Yes, that's found on
25   page --
0121
 1             MR. BONEZZI:   You're talking
 2   about different times.  If you look at the
 3   graphics, and maybe the graphics are
 4   incorrect, but the 101.6 is at 1925, and the
 5   heart rate and the respiration rate that
 6   you're quoting are at 2015.
 7             MR. GORDON:   In all due respect,
 8   I'm looking at --
 9             MR. BONEZZI:   I'm just looking at
10   the graphics; that's all.
11             MR. GORDON:   Okay.  According to
12   the -- let's look at the -- according to the
13   nurses' notes on page 160 --
14             MR. JEFFERS:   What time?
15             MR. GORDON:   At 2024 on June
16   25th, this is when they had a phone check
17   with you.
18             MR. BONEZZI:   Uh-huh.
19             MR. GORDON:   Okay?  So, that
20   would be 8:24 in the evening.
21   BY MR. GORDON:
22   Q    Okay, Doctor, and that's the time,
23   according to the nurses' notes, rather than
24   the 7 -- that's the time I am using that you
25   received this phone call, okay?
0122
 1   A    Okay.
 2   Q    Is that a reasonable time to assume?
 3   A    Yes.
 4   Q    Okay.  Therefore, the -- the blood
 5   pressure reading, heart rate and respiration
 6   rate, I'm using the nurses' notes records on
 7   page 140 for that information.
 8             MR. BONEZZI:   And what was --
 9   what was the blood pressure?
10             MR. GORDON:   119 over 93.
11             MR. BONEZZI:   Thank you.
12             MR. GORDON:   So we know where
13   that is.  Now  --
14             MR. BONEZZI:   So, it's just the
15   temperature that's out of whack.
16             MR. GORDON:    Okay.
17             THE WITNESS:   I'm sorry.  Repeat
18   again where you're -- where you're looking
19   at.
20   BY MR. GORDON:
21   Q    Page 140.
22   A    Okay, at the top.
23   Q    On the right-hand side --
24   A    Okay.
25   Q    -- at 2015 or 8:15.
0123
 1   A    Okay.
 2   Q    Do you see that?  It says blood
 3   pressure 119 over 93, pulse 102, respiration
 4   -- respiration 22.
 5   A    Okay.
 6   Q    Are you with me?
 7   A    Yes.
 8   Q    Okay.  Now, according to the medication
 9   sheet, page 58 --
10             MR. PARIS:      Let's go off the
11   record a minute.  He's got to change the
12   tape.
13             THE VIDEOGRAPHER:   Off the
14   record.
15             (At this time a short recess was
16   had.)
17             MR. GORDON:   All right.  We're
18   back on the record.  Okay.
19   BY MR. GORDON:
20   Q    I wanted to direct your attention to
21   one thing before we move on.  On page 58,
22   it's the medications, and it says Tylenol
23   was given at 1700 or 5:00, okay?
24   A    Yes.
25   Q    That time would be before the 101.6
0124
 1   degree Fahrenheit temperature; is that
 2   correct?
 3   A    About three hours before, yes.
 4   Q    Okay.  Does -- it's 19 -- we're talking
 5   about 1925 as the time for the -- 1925 on
 6   page 140 was the time of -- of the
 7   temperature of 101.6, okay?
 8   A    Uh-huh.
 9   Q    Assume that's true.  So, it's like two
10   and a half hours.
11   A    Uh-huh.
12   Q    Okay.  First of all, does Tylenol
13   suppress or decrease a temperature?
14             MR. BONEZZI:   Objection to the
15   form of the question.  At what point in time
16   would it decrease are you asking?
17             MR. GORDON:   Generally speaking.
18             MR. BONEZZI:   No, at its peak
19   efficiency, or what's the half life?
20   Harley, don't ask a question unless you ask
21   the entire one.  When, at its peak
22   efficiency --
23             MR. GORDON:    I'm just asking a
24   general question.  You could say --
25             MR. BONEZZI:   No, I'm not going
0125
 1   to let him answer it, because you have to
 2   give it, and then there's going to be a
 3   certain point in time when the Tylenol or
 4   whatever the other medication becomes
 5   effective.  That's all I'm asking you.
 6             MR. PARIS:     It's impossible to
 7   ask questions with the specificity that
 8   you're demanding.
 9             MR. BONEZZI:   No, it's not.
10             MR. PARIS:     I mean, this man is
11   asking a very simple question.
12             MR. BONEZZI:   No.  Every -- you
13   all -- you both know what -- wait, you both
14   know what the half life is, and you both
15   should know, if you're going to ask that
16   question, when Tylenol No. 3 hits its peak
17   efficiency.
18             MR. PARIS:     Let the witness
19   tell him that.
20             MR. BONEZZI:   No.
21             MR. PARIS:     Why -- why should
22   you --
23             MR. BONEZZI:   Because why -- why
24   -- why should you ask a question in a vacuum
25   like that?
0126
 1   BY MR. GORDON:
 2   Q    All right, all right, all right, all
 3   right.  Let me rephrase the question, okay?
 4   Okay?
 5   A    Uh-huh.
 6   Q    Would a Tylenol be given -- being given
 7   at 1700, five p.m. have any tendency to
 8   decrease or depress a temperature within the
 9   next two to three hours?
10   A    Possibly.
11   Q    Okay.  Is it possible that the
12   temperature recorded at 101.6 degrees
13   Fahrenheit at 1925 was suppressed to some
14   degree by the Tylenol?
15             MR. BONEZZI:   Objection.  You can
16   answer.
17   BY MR. GORDON:
18   Q    Given at 1700.
19   A    It's possible, but, again, the degree
20   of fever in the first 24 hours does not
21   indicate whether or not an infection is
22   present, and fever degree does not correlate
23   with the severity of infection.
24   Q    Okay.  Then, what is the half life of
25   Tylenol No. 3?  Do you know?
0127
 1   A    It's administered every four to six
 2   hours.  So, its half life is about two
 3   hours.
 4   Q    Mr. Bonezzi wasn't kind enough to give
 5   us that information.
 6             MR. BONEZZI:   You didn't ask me.
 7   I would have told you.
 8             MR. PARIS:     We wanted to make
 9   sure you knew that.
10   BY MR. GORDON:
11   Q    Okay, but anyway, let's -- another
12   thing is, on -- on page 160, according to
13   the nurses' notes --
14             MR. JEFFERS:   Page what?
15             MR. BONEZZI:   One sixty.
16   BY MR. GORDON:
17   Q    One sixty, in the left-hand column, the
18   line 2000 or eight p.m., ice was -- "ice
19   packs to back of neck for comfort related to
20   elevated temperature" is noted, okay?  Do
21   you see that?
22   A    Yes.
23   Q    Okay.  Would ice packs to the back of
24   the neck at this time, 20 -- 2000 -- just
25   generally speaking, would ice packs to the
0128
 1   back of the neck have an effect of
 2   depressing or suppressing temperature?
 3   A    Sure, yes.
 4   Q    And why?
 5   A    Ice cools.
 6   Q    Okay.  So, if you have -- do you, as a
 7   doctor, take into consideration that ice
 8   packs were given to a patient to depress
 9   temperature, that the temperature that you
10   have after that might be higher than was
11   actually recorded?
12             MR. BONEZZI:   Objection to the
13   form.  Go ahead and answer.
14             THE WITNESS:   Well, certainly, a
15   -- I would -- I didn't know this patient had
16   ice packs, and, B, how long were the ice
17   packs applied?  Were they replaced?  You
18   know, it could affect the future reading of
19   a temperature if the patient was packed in
20   ice, certainly.
21   BY MR. GORDON:
22   Q    How about just ice packs behind the --
23   behind the neck?
24   A    For how long?  When was the next
25   reading done?
0129
 1   Q    Continuously.
 2   A    Does that say that here?  I don't know
 3   that she says she had it.
 4   Q    Assuming that's true.
 5   A    If it was continuously placed, they
 6   could potentially affect her temperature.
 7   Q    They'd drop the temperature?
 8   A    Yes.
 9   Q    Okay.  Then one last question in terms
10   of giving a Tylenol.  Then, are you saying
11   that it's not contraindicated within the
12   first 24 hours after the delivery to give a
13   patient Tylenol even though there is an
14   elevated temperature?
15   A    That is correct.
16   Q    Okay.  Then, let's go back to the
17   Discharge Summary report.  It says, at that
18   time, and you're talking about the call
19   regarding the -- either the 100.6 or the
20   101.6 degrees Fahrenheit.  "At that time her
21   pulse and vital signs were stable as I was
22   informed by the nursing staff with good
23   urine output."  Then, "Given the nature of
24   her delivery, and it was not more than 24
25   hours from delivery, and her Group B strep
0130
 1   culture being negative, she was given
 2   Tylenol and a UA."  Is that urinalysis?
 3   A    Yes.
 4   Q    "C&S" is culture and sensitivity; is
 5   that right?
 6   A    Yes.
 7   Q    "-- was sent, and I was to be called if
 8   any further -- further fevers occurred,"
 9   okay.
10   A    Uh-huh.
11   Q    Those -- first of all, then, your
12   instructions to the -- the nursing staff was
13   to call you if there was any further fevers?
14   A    Yes.
15   Q    Fever being what, what parameter?
16   A    Again, anything greater -- the nurses
17   would call for anything greater than 100.5
18   to 101.
19   Q    100.5?
20   A    Uh-huh.
21   Q    Not 100.4?
22   A    Correct.
23   Q    And did you give the nurse any
24   instructions as to when to take the
25   temperature?
0131
 1   A    No.
 2   Q    You left it up to her to take it every
 3   hour or every two hours, every three hours?
 4   A    Yes.
 5   Q    Okay, and why did you order a
 6   urinalysis?
 7   A    If, in fact, a patient was going to
 8   develop an infection, the most likely
 9   infection could be cystitis.  I wanted to
10   make sure there wasn't evidence of an early
11   infection there.
12   Q    Okay, but, so, can we agree you were
13   at least considering that this temperature
14   --
15   A    Uh-huh.
16   Q    -- that you were told about might be an
17   infection?
18             MR. BONEZZI:   Objection to form.
19   Go ahead and answer.
20             THE WITNESS:   Any fever could be
21   an infection.
22   BY MR. GORDON:
23   Q    All right.  So, you're trying to
24   determine whether, indeed, there was an
25   infection; is that correct?
0132
 1   A    I was trying to determine if there were
 2   signs of an infection in her urinalysis.
 3   Q    Okay.  Looking at page 179, on the
 4   orders at 2020, your order for the
 5   urinalysis was not recorded; is that
 6   correct?
 7   A    2020 there's an order.  It says,
 8   "Obtain urine sample by catheter for culture
 9   and sensitivity."
10   Q    Not for a urinalysis?
11   A    That's correct.
12   Q    Okay, and a urinalysis should have been
13   done?
14   A    It was ordered.
15   Q    Okay, and assume hypothetically a
16   urinalysis was not done.  The nurse did not
17   follow your orders.
18             MR. SCHOBERT:  Object.
19             THE WITNESS:   That would be
20   correct.
21   BY MR. GORDON:
22   Q    And would you agree that it would be a
23   departure from nursing care for a nurse not
24   to follow your orders?
25             MR. BONEZZI:   Objection to the
0133
 1   form.  Go ahead and answer, if you can.
 2             THE WITNESS:   Yes.
 3   BY MR. GORDON:
 4   Q    Okay.  This urinalysis was a critical
 5   piece of information that you wanted; is
 6   that correct?
 7             MR. BONEZZI:   Objection to
 8   "critical."  Go ahead and answer.
 9             THE WITNESS:   Yes.
10   BY MR. GORDON:
11   Q    Okay.  You did the culture and
12   sensitivity order for the same reason, that
13   you wanted to see if there was any bacteria
14   or infection in -- in the urine; is that
15   correct?
16   A    That's correct.
17   Q    Okay.  Now, you stated here, "Given the
18   nature of her delivery, and it was not more
19   than 24 hours from the delivery, and her
20   Group B strep culture being negative"; can
21   you explain that, what your thinking was?
22   A    Uh-huh.  Group B strep is -- is one of
23   the rare instances where you'll have a -- an
24   infection that can develop more quickly post
25   -- in a postpartum patient.
0134
 1   Q    Okay.  Is what I've read to you about
 2   "given the nature of the delivery, and it
 3   was not more than 24 hours from delivery,"
 4   you're writing here what you were telling me
 5   in your testimony about a temperature --
 6   temperature elevations within 24 hours; is
 7   that it?
 8   A    That's right.
 9   Q    Okay.  Now, let's go to now -- the next
10   time you were contacted --
11   A    Uh-huh.
12   Q    -- and this, according to the nurses'
13   notes, and you'll turn to page 160, is --
14   it's on the left-hand column.  It has June
15   26th, '99, 0045 or 12:45 a.m., and it says,
16   "Dr. Hahn called."
17   A    Uh-huh.
18   Q    Do you see that?
19   A    Yes.
20   Q    Okay.  Your Discharge Summary report
21   says, "I received a call at 11:00 at night
22   that the patient was somewhat irritated and
23   restless, and her vital signs were stable."
24   Okay?
25   A    (At this time the witness nodded his
0135
 1   head.)
 2   Q    Is your 11:00 time incorrect?
 3   A    Yes.
 4   Q    The time should be 12:45 a.m.
 5   A    That is correct.
 6   Q    Okay.  Now, now, then, let me go on.
 7   So, what I'm reading now relates to the
 8   12:45 a.m. time, okay?  "Her most recent
 9   labs I was informed were well within normal
10   limits, and she was given Ativan 0.5 to 1
11   milligrams IV every eight hours."  Okay?
12   A    Uh-huh.
13   Q    That -- that, what I've just read,
14   occurred around 12:45 a.m.
15   A    (At this time the witness nodded his
16   head.)
17   Q    Is that right?
18   A    Yes.
19   Q    Going on, it says, "During the night at
20   around 3:00 in the morning, I received a
21   phone call that she had an episode of
22   vaginal bleeding.  An examination was done
23   by Dr. Hsieh, revealed no evidence of
24   retained products in the vagina.  A rectal
25   exam was done.  It was also normal.  Her
0136
 1   vital signs were reported as normal to me at
 2   that point as well."  Okay?
 3   A    (At this time the witness nodded his
 4   head.)
 5   Q    Am I correct that your 3:00 time is --
 6   is incorrect?
 7   A    Yes.
 8   Q    The actual facts that we just read
 9   regarding the rectal exam and so forth
10   occurred as part of the 12:45 a.m. call.
11   A    That's correct.
12             MR. SCHOBERT:  Objection.
13             THE WITNESS:   Yes.
14   BY MR. GORDON:
15   Q    Now, were you -- first of all, who
16   called you?
17   A    The -- at the --
18   Q    12:45 a.m.
19   A    The nurse.
20   Q    And what nurse was that?
21   A    Uh --
22   Q    Do you have an independent recollection?
23   A    No, I don't.
24   Q    Okay.
25   A    Other than what's documented here.
0137
 1   Q    Do you have an independent recollection
 2   of what occurred during that conversation?
 3   A    Uh-huh, uh-huh.
 4   Q    You do?
 5   A    Yes.
 6   Q    What is your independent recollection?
 7   A    I recall that she called, complained
 8   that the patient had -- was a little bit
 9   restless and agitated, tired of having her
10   Foley, and tired of being bed confined, and
11   that Dr. Hsieh had been called to the room
12   to evaluate the patient for an episode of
13   increased vaginal bleeding, and that he had
14   done a complete assessment on her, and found
15   no evidence of retained products of
16   conception on examination, that her uterus
17   was firm.  He had done a vaginal and rectal
18   exam, and that her episiotomy did not appear
19   to be bleeding, and she updated me with her
20   most recent lab values including her
21   hematocrit, her platelet count and her
22   magnesium level.
23   Q    How about the white blood count?
24   A    I wasn't informed of the white blood
25   count.
0138
 1   Q    I'm sorry.  At 12:45 a.m., you were not
 2   -- strike that.
 3             At 12:45 a.m. on June 26th, were
 4   you told by the nurse of the white blood
 5   count and differential?
 6   A    No.
 7   Q    How do you know that?
 8   A    Well, in retrospect, it was abnormal.
 9             MR. SCHOBERT:  I'm sorry.  I
10   couldn't hear the answer.
11             THE WITNESS:   In retrospect, the
12   value was abnormal.
13   BY MR. GORDON:
14   Q    So, you would have remembered that?
15   A    Yes.
16   Q    Okay.  All right.  Well, let's go to
17   the -- the lab values.  This is found on
18   page 42.
19             MR. JEFFERS:   What page?  I'm
20   sorry.
21             MR. GORDON:   Page 42.
22   BY MR. GORDON:
23   Q    The white blood count we're talking
24   about is -- strike that.
25             The lab values that the nurse did
0139
 1   -- did not tell you, were those here on page
 2   42 of 2330?
 3   A    That's correct.
 4   Q    That is the white blood count of 4.6?
 5   A    Uh-huh.
 6   Q    Is that correct?
 7   A    Yes.
 8   Q    The bands of 52?
 9   A    That's correct.
10   Q    The metamyelocytes of 6?
11   A    Yes.
12   Q    And the neutrophils of 33.
13   A    Correct.
14   Q    Did you ask the nurse to give you the
15   lab values including the white blood count
16   and differential?
17   A    I don't recall specific -- specifically
18   asking her for that, and  --
19             MR. BONEZZI:   That was the
20   question.  Did you --
21   BY MR. GORDON:
22   Q    Do you want to explain your answer?
23   A    No.
24   Q    Okay.  Is it, from your custom and
25   practice, more likely than not that you
0140
 1   would have asked the nurse to give you the
 2   lab values including the white blood count
 3   and differential?
 4   A    No.
 5   Q    Why is that?
 6   A    Again, in a patient who has
 7   pre-eclampsia, we're most concerned with
 8   their hematocrit and their platelet count in
 9   the CBC.
10   Q    The hematocrit, hemoglobin?
11   A    And platelet count.
12   Q    Okay, and in this case, magnesium as
13   well.
14   A    Yes.
15   Q    Okay.
16   A    And liver functions.
17   Q    And is it your testimony then that the
18   nurse did provide you with the hematocrit,
19   hemoglobin, platelet and magnesium values?
20   A    Yes.
21   Q    But did not give you the white blood
22   count and differential?
23   A    That's correct.
24   Q    So, then, is it your testimony that you
25   expected the nurse to advise you of any
0141
 1   abnormalities in the white blood count as
 2   well as the differential?
 3   A    Yes.
 4   Q    Why did you expect the nurse to tell
 5   you that?
 6   A    I expected that they would recognize
 7   that this was abnormal.
 8   Q    And why do you expect a nurse to tell
 9   you abnormal values?
10   A    That's their job in the care of a
11   patient in -- in the -- we're not physically
12   at the bedside.  They're our eyes and our
13   ears, and they observe what's happening.
14   Q    You -- do you expect nurses to give you
15   abnormal lab values including abnormal white
16   blood count and differential because that
17   helps you make treatment decisions with
18   regard to a patient?
19   A    I would expect a nurse to give me
20   values that fall outside the range so that I
21   can make those choices about how I would
22   manage the patient.
23   Q    Okay, and did the nurse who talked to
24   you at 12:45 a.m. deviate from accepted
25   standard of nursing care by failing to give
0142
 1   you the abnormal white blood count and
 2   differential?
 3             MR. BONEZZI:   Objection.
 4             MR. JEFFERS:   Objection.
 5             THE WITNESS:   It should have been
 6   reported to me.
 7   BY MR. GORDON:
 8   Q    Okay, and from your standpoint as a
 9   physician working with a nurse, did -- did
10   the nurse at 12:45 a.m. who failed to give
11   you those values outside of the normal
12   range, did she depart from accepted
13   standards of nursing care?
14             MR. BONEZZI:   Objection.
15             MR. JEFFERS:   Object.
16             THE WITNESS:   Yes.
17   BY MR. GORDON:
18   Q    Now, assume hypothetically that you
19   knew of the white blood count that's
20   recorded here at 2330 of 4.6, okay, and you
21   had the previous white blood count of 6.1.
22             MR. JEFFERS:   Of what?
23   BY MR. GORDON:
24   Q    16.1.  How would you have used that
25   information, if at all, in making management
0143
 1   decisions?
 2   A    Well, it would be a concern that
 3   there's something unusual going on with the
 4   patient, and potentially an infection
 5   somewhere, but, again, as an isolated fact,
 6   it's difficult to interpret that.
 7   Especially without a fever, another fever,
 8   that's very unusual.
 9   Q    All right, we'll get to that, but let's
10   talk about, does the drop in white blood
11   count from 16.1 to 4.6 indicate to you that
12   there's an infection in and of itself, just
13   the drop?
14   A    It -- it makes me concerned about an
15   infection.
16   Q    Okay.  Then, you have the bands are 52,
17   and that's -- and with the neutrophils at
18   33, that's a left shift; is that correct?
19   A    Yes, yes.
20   Q    That information would also concern you
21   that there might be an infection; is that
22   correct?
23   A    Yes.
24   Q    In addition, you have metamyeolocytes
25   of six which are well outside of the normal
0144
 1   range; is that correct?
 2   A    Yes.
 3             MR. BONEZZI:   Objection to the
 4   form.
 5             MR. GORDON:   It's my
 6   characterization.
 7   BY MR. GORDON:
 8   Q    Outside of the normal range, right,
 9   metamyelocytes of six.
10   A    Yes.
11   Q    Okay, and that also would concern you
12   regarding the patient had an infection?
13   A    Uh-huh.
14   Q    Is that correct?
15   A    Yes.
16   Q    Would the white blood count of 4.6,
17   bands of 52, metamyeolocytes of six and
18   neutrophils of 33 -- 33, would that, in
19   terms of your thinking, bring to mind that
20   the patient might have a severe infection?
21   A    It would -- it would be in the
22   differential diagnosis.
23   Q    Okay.  Would it -- and part of the
24   differential diagnosis with the white blood
25   count readings I've given you including the
0145
 1   differential, would you start thinking of
 2   sepsis?
 3             MR. BONEZZI:   Objection.  Go
 4   ahead and answer.
 5             THE WITNESS:   Not sepsis.  I
 6   mean, I would think of an infection.
 7   BY MR. GORDON:
 8   Q    Okay.  In -- in terms of -- now, let's
 9   talk about, you said another component would
10   be fever.  The nurses' notes at page 142 --
11   let's see; I'm sorry.  Yes, at page 142 --
12   A    Uh-huh.
13   Q    -- okay, the temperature is recorded at
14   100.4; is that correct?
15   A    Where is that?  I'm sorry.
16   Q    Right on the right-hand side.
17   A    Uh-huh.
18             MR. SCHOBERT:  What time?
19             MR. GORDON:    The time at 12:30.
20             THE WITNESS:   Yes, I see that.
21   BY MR. GORDON:
22   Q    Okay.  Would the -- and then the 100.4
23   converts to 38 degrees Centigrade; is that
24   correct?
25   A    Yes.
0146
 1   Q    But that's --
 2   A    Yes.
 3   Q    Okay.  Were you told of the temperature
 4   of 100.4 degrees Fahrenheit by the nurse?
 5   A    No.
 6   Q    Did you expect to be told by the nurse
 7   that the patient had a temperature of 100.4
 8   degrees Fahrenheit?
 9   A    No, because in our institution, 100.5
10   is considered a fever.
11   Q    Would you have been interested,
12   however, to know that the fact that the
13   patient had given -- been given Tylenol at
14   2100 hours and had ice packs to her neck, as
15   it relates to the temperature?
16   A    I wasn't informed of that.
17   Q    Okay, but would that -- should --
18   should that information, in terms of the
19   Tylenol and the ice packs, be given to you?
20             MR. BONEZZI:   Objection.
21             THE WITNESS:   I -- to note -- to
22   note if she had a fever, an elevated fever,
23   yes.  I mean, that could potentially impact
24   her temperature, and that should impact
25   their interpretation of the temperature.
0147
 1   BY MR. GORDON:
 2   Q    Okay.  Did you ask the nurse to give
 3   you what the temperature was?
 4   A    I don't recall specifically if I did.
 5   Q    If you had known that the patient had
 6   been given Tylenol at 2100 and had been
 7   given ice packs continuously through that
 8   time frame --
 9             MR. BONEZZI:   Objection.
10   BY MR. GORDON:
11   Q    -- okay, and you knew of the
12   temperature of 100.4 degrees Fahrenheit --
13   A    Uh-huh.
14   Q    -- would you have felt that the
15   temperature could even be higher?
16   A    Yes.
17   Q    Just to -- to a range beyond 100.5
18   degrees Fahrenheit, to that range or beyond?
19   A    I -- I can't speculate.  That's --
20   Q    Okay.  Assuming you had known of the
21   100.4 degrees Fahrenheit temperature --
22   A    Uh-huh.
23   Q    -- as well as the white blood count and
24   differential readings at 20 -- which are
25   recorded on page 42 under the line 2330 --
0148
 1   A    Uh-huh.
 2   Q    -- how would you have used that
 3   information to manage this patient?
 4   A    I would have been much more concerned
 5   about an infection.
 6   Q    Why?
 7   A    Because of the abrupt change in her
 8   white count mostly.
 9   Q    Okay, then  -- then, what would you
10   have done in terms of the management of this
11   patient if you were aware of the white blood
12   count --
13   A    Uh-huh.
14   Q    -- of 2330 and the -- the differential?
15   A    Uh-huh.  I would have ordered the house
16   physician to, you know, repeat his physical
17   assessment of the patient, and I probably
18   would have repeated the white count again,
19   because that's a very abrupt change.
20   Q    Okay.  That's all you would have done?
21   A    At that point, yeah, that's what I
22   would have done.
23   Q    What would you have -- I'm sorry?
24   A    I would have ordered that information
25   to confirm that there was such an abrupt
0149
 1   change in the white count.
 2   Q    Okay.  Would the fact that -- let's --
 3   let's -- would the fact that the patient had
 4   a pulse rate of 125 around that time frame,
 5   would that impact on your management
 6   decisions?
 7             MR. JEFFERS:   Okay.
 8             THE WITNESS:   Where -- I mean, I
 9   want to see the pulse here.
10   BY MR. GORDON:
11   Q    Okay.  Page --
12             MR. BONEZZI:   It's on the
13   graphics.
14   BY MR. GORDON:
15   Q    On page -- on page 189, Dr. Hsieh has a
16   pulse rate of 125.
17   A    Uh-huh.
18   Q    Then, the nurse's note, which we looked
19   over earlier on page 142, has a pulse rate
20   of 128.
21   A    Uh-huh.
22   Q    Okay.  How would those heart rates
23   impacted upon your management decision, if
24   any?
25   A    That's -- that's a change again from
0150
 1   what she was previously.
 2   Q    And would that reinforce your
 3   impression that there might be an infection?
 4   A    It  -- well, an elevated pulse can be
 5   from a number of things, infection being one
 6   of them.
 7   Q    Okay, yeah.  Were you told by the nurse
 8   that you talked to at 12:25 A.M. that the
 9   patient did have a heart rate of 125 or 128?
10   A    Uh-huh.  I don't recall specifically.
11   I mean, again, the -- the nature of the
12   conversation was that this patient is
13   stable.  Dr. Hsieh has just examined her.
14   Her -- at least what appeared to be relevant
15   labs to the nurse were within normal limits,
16   and the patient is restless and wants to get
17   out of bed, and doesn't like having her
18   Foley catheter in.
19   Q    Well, would, then -- if you have a
20   temperature of 100.4, blood pressure 119
21   over 64, a pulse rate of 128, and a
22   respiration rate of 18, would you consider
23   those vital signs as stable individually or
24   collectively?
25             MR. BONEZZI:   Would you read
0151
 1   those back, please?
 2   BY MR. GORDON:
 3   Q    I'm looking at page 142.
 4             MR. BONEZZI:   Yeah.
 5             THE WITNESS:   Okay.
 6             MR. JEFFERS:   One forty what?
 7             MR. GORDON:   Two.
 8             THE WITNESS:   Uh-huh.  Again --
 9   BY MR. GORDON:
10   Q    Do you want me to repeat those?
11             MR. BONEZZI:   Would you, please,
12   yes.  That's fine.
13   BY MR. GORDON:
14   Q    I'll go back.  On page 142, Doctor,
15   under --
16   A    Uh-huh.
17   Q    -- 0030 or 12:30 a.m. there's a
18   temperature of 100 degrees -- 100.4 degrees
19   Fahrenheit --
20   A    Uh-huh.
21   Q    -- blood pressure of 119 over 64; a
22   pulse of 128; respirations 18.  Would you
23   consider those vital signs collectively
24   stable or individually stable?
25   A    I would say they're collectively stable
0152
 1   and also, I mean, her pulse, I've got a
 2   phone call about a patient who's agitated.
 3   I would expect an elevation in her pulse for
 4   that reason.
 5   Q    All right.  Now, you said, if you had
 6   been informed of the white blood count and
 7   differential, that you would have ordered
 8   the house officer to do a physical exam.
 9   Could you tell me what you would have
10   ordered him to do --
11   A    Take --
12   Q    -- in terms of the physical exam?
13   A    Oh, looking -- looking for a sign of
14   infection, checking her IV sites, checking
15   her epidural site, checking her episiotomy,
16   seeing if her uterus was tender, did she
17   have foul lochia, listen to her lungs.  Did
18   she have a pneumonia or something like that
19   developing?  Does she have other underlying
20   illness?  Did she come in with a cold or a
21   sinusitis?
22   Q    You all -- is that the extent of the
23   instructions you would give the house
24   officer in terms of physical exam?  In other
25   words, would you ask him to do vital signs?
0153
 1   A    Well, if the vital signs are
 2   continuously being done by the nursing
 3   staff, I wouldn't specifically ask the
 4   physician to do that.
 5   Q    And then you would order -- you would
 6   request the house officer to order a
 7   complete blood count?
 8   A    Uh-huh.  I would repeat the blood count.
 9   Q    On a stat basis?
10   A    Yes.
11   Q    So, you'd get it back within a half an
12   hour or so?
13   A    Yes, uh-huh.
14   Q    Including a differential.
15   A    Yes.
16   Q    And you would order the complete blood
17   count to -- to assure you that the readings
18   that you received at 2330 were, indeed,
19   true.
20   A    Yes.
21   Q    Or accurate?
22   A    Yes.
23   Q    Okay.  Then, assume hypothetically that
24   the white blood count that was ordered came
25   back within the -- within the -- with the
0154
 1   same values.
 2   A    Uh-huh.
 3   Q    What would you have done in that
 4   instance?
 5   A    That would depend on the nature of the
 6   physical exam.
 7   Q    Okay, and there is a normal physical
 8   exam.
 9   A    Then, I wouldn't be sure.  I mean,
10   honestly, I would typically -- in a 24-hour
11   period, we would observe such a patient, but
12   with such a dramatic shift in white count, I
13   mean, I would either follow her very closely
14   again or -- at the time or consider starting
15   antibiotics at that point.
16   Q    So, you'd observe her for how long?
17   A    An hour or two, I mean, to, you know,
18   see if her white count, you know, declined
19   or worsened with the second draw, and that
20   would be certainly an indication to you that
21   there's some process going on that you have
22   yet to identify.
23   Q    Or, alternatively, you would have
24   instituted antibiotics?
25   A    Right, but, typically, you -- you find
0155
 1   something on your physical exam in patients
 2   that are infected.  It's unusual not to.
 3   Q    Okay.  Would you have, let's say with
 4   the initial -- let's say if you had been
 5   told initially of the 2330 white blood count
 6   and differential, would you have presumed an
 7   infection until proven otherwise?
 8   A    Not necessarily.
 9   Q    Would you have presumptively assumed
10   that the patient was septic with the white
11   blood count reading and differential reading
12   as reported under the 2330 column?
13   A    No.
14   Q    Would you -- why wouldn't you presume
15   the patient was septic?
16   A    Her vital signs are -- are stable.
17   Usually with sepsis you'll see either an
18   elevated pulse with drop in blood pressure.
19   You'll see a change in urine output.
20   Q    Would you have presumed with the white
21   blood count readings as well as the
22   differential under 2330 that -- you would
23   presume that she had a severe infection?
24             MR. BONEZZI:   Objection.  Go
25   ahead and answer.
0156
 1             MR. SCHOBERT:  Objection.
 2             THE WITNESS:   I would not presume
 3   that, as I stated previously.
 4   BY MR. GORDON:
 5   Q    Okay.
 6             MR. JEFFERS:   You're dropping
 7   your voice a little.
 8             THE WITNESS:   I'm sorry.
 9   BY MR. GORDON:
10   Q    Okay, and the antibiotics -- if you did
11   order antibiotics after getting the repeat
12   white blood count, you would order what type
13   of antibiotics?
14   A    Broad spectrum antibiotic.  I typically
15   use Unasyn as my first choice.
16   Q    Why Unasyn?  What are you -- what do
17   you intend to cover with that antibiotic?
18   A    Most of the common pathogens that cause
19   uterine infections, and they're -- strep are
20   common, peptococcus, anaerobes, gram
21   negative bacteria like E-coli.
22   Q    And what dose would you have ordered?
23   A    Three grams.
24   Q    For what --
25   A    Oh, intravenously every six hours.
0157
 1   Q    Is that the same dose that you ordered
 2   at ten a.m. on June 26th --
 3   A    Yes.
 4   Q    -- shown on page 180; is that right?
 5   A    Yes.
 6   Q    Okay.
 7   Q    Let me just take a short break.
 8             MR. BONEZZI:   Sure.
 9             MR. GORDON:   I want to complete
10   this, and then we'll probably -- okay.
11   Because this is --
12             THE VIDEOGRAPHER:   Off the
13   record.
14             (At this time a short recess was
15   had.)
16             THE VIDEOGRAPHER:   Back on the
17   record.
18   BY MR. GORDON:
19   Q    Doctor, we were talking about, assuming
20   hypothetically you were aware of the white
21   blood count and differential reported under
22   the column 2330, and then you gave us what
23   you would do, a physical exam and then
24   repeat CBC, okay.  The question is:  if you
25   had a repeat physical exam which was in
0158
 1   normal limits, and a CBC came back similar
 2   to what was at 2330, but in the next one to
 3   two hours, the patient developed uterine
 4   cramping and had a distended abdomen, can
 5   you tell me what you would have done under
 6   those circumstances hypothetically?
 7             MR. JEFFERS:    Object.  Object.
 8             THE WITNESS:   Now, if I knew
 9   about her white count, and she had a
10   distended abdomen?
11   BY MR. GORDON:
12   Q    No, under the --
13   A    I'm sorry.
14   Q    If -- we were talking about you had the
15   white blood count reading.
16   A    Uh-huh.
17   Q    And you would have ordered a physical
18   exam and repeat CBC.
19   A    Uh-huh.
20   Q    So, beginning there, if the physical
21   examination which you had ordered was within
22   normal limits, and the CBC came back similar
23   to what was identified at the reading under
24   2330 --
25   A    Uh-huh.
0159
 1   Q    -- all right, but in the next one to
 2   two hours, the patient developed uterine
 3   cramping and a distended abdomen --
 4   A    Uh-huh.
 5   Q    -- what would your management decisions
 6   have been at that point?
 7   A    Again, I would -- at that point, I
 8   would institute a repeat physical
 9   examination.
10   Q    To confirm --
11   A    To see what -- you know, who told me
12   the patient's abdomen was distended?  Are
13   there bowel sounds?  What sort of bleeding
14   or -- cramping is -- is a non -- I mean, all
15   postpartum patients cramp.
16   Q    And if you had diminished bowel sounds
17   also within the one to two hours, would that
18   impact on your management decisions?
19   A    No.
20   Q    Why is that?
21   A    Because she's on magnesium, and
22   magnesium slows bowel motility.
23   Q    Oh, boy.  At what point in this
24   presentation would your index of suspicion
25   for infection cause you to order blood
0160
 1   cultures and antibiotics?
 2   A    Uh-huh.  I'm not sure  --
 3             MR. BONEZZI:   Did you understand
 4   that question?
 5             THE WITNESS:   No, I don't.
 6   BY MR. GORDON:
 7   Q    What -- what would you -- what clinical
 8   information or lab values involved --
 9   A    Uh-huh.
10   Q    -- would you need to have received in
11   order to order, first of all --
12   A    Uh-huh.
13   Q    -- blood cultures and antibiotics?
14   A    If I --
15             MR. BONEZZI:   Objection.  Go
16   ahead and answer.
17             MR. SCHOBERT:  Yes.  Objection.
18             THE WITNESS:   If the second set
19   of white count came back the same, and I
20   made a decision -- I would probably draw
21   blood cultures then regardless, you know, of
22   whether or not I was going to institute
23   antibiotics, but if there was some change in
24   physical exam, if her uterus was tender, if
25   there was, you know, a foul lochia --
0161
 1   BY MR. GORDON:
 2   Q    How about vital signs?
 3   A    If there was a change -- if her blood
 4   pressure began to decline.
 5   Q    Then, according to the nurse's notes,
 6   she documents at 0045 a.m., "Dr. Hahn called
 7   and informed of lab results," okay.
 8   A    What page are you on?
 9   Q    160.  Do you see where I am?
10   A    I'm getting there.  0445?
11   Q    0045.
12   A    Oh, 0045, yes.
13   Q    "-- and informed of lab results," and,
14   then, "patient's status, restlessness,
15   anxiety, output."
16   A    Uh-huh.
17   Q    So, would you agree, the nurse did
18   advise you of the restlessness and anxiety;
19   is that correct?
20   A    Yes.
21   Q    And the output?
22   A    Output being urine output, yes.
23   Q    All right, and do you remember what the
24   nurse told you about the output?
25   A    No.  I mean, it was within -- it was
0162
 1   acceptable within the range of a patient who
 2   has pre-eclampsia, as we previously spoke,
 3   greater than 30 ccs per hour.
 4   Q    Okay.  Did you find anywhere in these
 5   records, either at 0045 or even earlier,
 6   anything in the record documenting vaginal
 7   bleeding?
 8   A    When Dr. Hsieh -- sorry.  Yeah, at
 9   12:25.
10             MR. BONEZZI:   Uh-huh, that's it.
11             THE WITNESS:   At 12:25 Dr. Hsieh
12   wrote a note, "No active bleeding from
13   vagina."
14   BY MR. GORDON:
15   Q    I'm saying that in your progress note
16   you indicated --
17             MR. BONEZZI:   Discharge Summary.
18   BY MR. GORDON:
19   Q    I'm sorry.  Strike that.  In your
20   Discharge Summary report, page three, you
21   indicated, "Patient had an episode of
22   vaginal bleeding."
23   A    Uh-huh.
24   Q    Okay.  Where did you get that
25   information from?
0163
 1   A    When the nurse had spoke to me, and Dr.
 2   Hsieh had examined the patient.
 3   Q    Okay, but do you see anywhere in the
 4   record before Dr. Hsieh saw this patient
 5   that there was some documentation of vaginal
 6   bleeding?
 7   A    Not by the nurses, but that was the
 8   main reason that he was called to the room.
 9   Q    How do you know that?
10   A    When I got the phone call.
11   Q    How do you know that?
12   A    The nurse advised me that she had
13   called Dr. Hsieh to the room because of an
14   episode of increased vaginal bleeding.
15   Q    Does the nurse document that episode of
16   vaginal bleeding in her -- in her nurses'
17   notes?
18   A    I did not see that, no.
19             MR. GORDON:    Okay.  Okay.
20   We'll take -- this is a good point to take a
21   recess.
22             THE VIDEOGRAPHER:   Off the
23   record.
24             (At this time the deposition was
25   recessed.)
0164
 1                    CERTIFICATE
 2   The State of Ohio,   )
 3   County of Cuyahoga.  )   SS:
 4       I, Luanne Stone, a Notary Public within
 5   and for the State of Ohio, duly commissioned
 6   and qualified, do hereby certify that the
 7   within-named witness, WILLIAM HAHN, JR.,
 8   M.D., was by me first duly sworn to testify
 9   to the truth, the whole truth and nothing
10   but the truth in the case aforesaid; that
11   the testimony then given by the
12   above-referenced witness was by me reduced
13   to stenotypy in the presence of said
14   witness; afterwards transcribed; and that
15   the foregoing is a true and correct
16   transcription of the testimony so given by
17   the above-referenced witness.
18       I do further certify that this
19   deposition was taken at the time and place
20   in the foregoing caption specified and was
21   completed without adjournment.
22       I do further certify that I am not a
23   relative, counsel or attorney for either
24   party, or otherwise interested in the
25   event of this action.
0165
 1       IN WITNESS WHEREOF, I have hereunto set
 2   my hand and affixed my seal of office at
 3   Cleveland, Ohio this ______ day of
 4   _______________, A.D., 2000.
 5   
 6   
 7                 ____________________________
 8                 Luanne Stone, f.k.a. Protz
 9                 Notary Public
10                 In and for the State of Ohio
11                 My commission expires 4/6/03
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