1 1 IN THE COURT OF COMMON PLEAS FOR THE STATE OF OHIO 2 COUNTY OF CUYAHOGA 3 4 MARK WILLIAMS, ETC., : PLAINTIFFS, : 5 : : 6 VS. : CASE NO. 406184 : 7 : PARMA COMMUNITY GENERAL : 8 HOSPITAL, ET AL., : Defendants : 9 10 **************************************************** ORAL VIDEOTAPED DEPOSITION OF 11 HUNTER A. HAMMILL, M.D. 12 MAY 31, 2001 **************************************************** 13 14 The oral and videotaped deposition of HUNTER A. 15 HAMMILL, M.D, produced as a witness at the instance 16 of the Plaintiff, Mark Williams, Etc., and duly 17 sworn, was taken in the above-styled and numbered 18 cause on the 31st day of May, 2001, from 2:10 p.m. to 19 4:18 p.m., before Nancy S. Landry, RPR, RMR, CSR in 20 and for the State of Texas, reported by machine 21 shorthand, at the offices of Hunter A. Hammill, M.D., 22 7400 Fannin Street, Suite 1160, Houston, Harris 23 County, Texas, pursuant to the Ohio Rules of Civil 24 Procedure and the provisions stated on the record or 25 attached hereto. CONTINENTAL COURT REPORTERS, INC. 2 1 A P P E A R A N C E S 2 3 FOR THE PLAINTIFFS MARK WILLIAMS, ETC.: 4 Mr. David M. Paris Mr. Harlan M. Gordon 5 Nurenberg, Plevin, Heller & McCarthy 1370 Ontario Street, Suite 100 6 Cleveland, Ohio 44113-1792 7 FOR THE DEFENDANT PARMA COMMUNITY GENERAL HOSPITAL: 8 Mr. John W. Jeffers 9 Weston, Hurd, Fallon, Paisley & Howley 2500 Terminal Tower 10 Cleveland, Ohio 44113 11 FOR THE DEFENDANTS DR. HAHN AND THE WOMEN & WELLNESS CENTER: 12 Mr. William D. Bonezzi 13 Bonezzi, Switzer, Murphy & Polito 1400 Leader Building 14 526 Superior Avenue Cleveland, Ohio 44114 15 FOR THE DEFENDANTS DR. HSIEH AND PHYSICIAN STAFFING: 16 Mr. Jeffrey E. Schobert 17 Hanna, Campbell & Powell 3737 Embassy Parkway 18 P.O. Box 5521 Akron, Ohio 44334 19 THE VIDEOGRAPHER: 20 Mr. Keith Bowman 21 Continental Legal Video Services 2777 Allen Parkway, Suite 600 22 Houston, Texas 77019 23 24 25 CONTINENTAL COURT REPORTERS, INC. 3 1 I N D E X 2 APPEARANCES .................................. 2 3 STIPULATIONS ................................. 1 4 HUNTER A. HAMMILL, M.D. 5 Examination by Mr. Paris ......... 4 Examination by Mr. Jeffers ....... 92 6 7 Signature and Changes ........................ 94 8 Reporter's Certificate ....................... 97 9 EXHIBITS 10 11 NO. DESCRIPTION PAGE 12 Exhibit No. 1 ............................ 4 A 16-page document entitled 13 "Hunter A. Hammill, M.D., FACOG, Curriculum Vitae." 14 Exhibit No. 2 ............................ 5 A 16-page document entitled 15 "Hunter A. Hammill, M.D., FACOG, Curriculum Vitae." 16 Exhibit No. 3 ............................ 92 A one-page document from 17 Hunter Hammill, M.D., to "To Whom it May Concern," dated 04/11/2001. 18 19 20 21 22 23 24 25 CONTINENTAL COURT REPORTERS, INC. 4 1 (Exhibit No. 1 marked) 2 VIDEOGRAPHER: This is the deposition of 3 Dr. Hunter Hammill, M.D., on May 31st, 2001, at 4 2:10 p.m, beginning Tape 1. 5 6 HUNTER A. HAMMILL, M.D., 7 having been first duly sworn, testified as follows: 8 9 EXAMINATION 10 BY MR. PARIS: 11 Q. Good afternoon, Dr. Hammill. My name is David 12 Paris, and I represent the Williams family in connection 13 with Beth's death. 14 I'm going to ask you some questions this 15 afternoon about your background and the opinions that 16 you hold in this case. If at any time I ask you a 17 question which is unclear for whatever reason, it's 18 important for you to stop me and tell me that and I'll 19 try to rephrase it. Will you do that? 20 A. I understand. 21 Q. Okay. And as you've done, it's important to 22 speak audibly so that we have an accurate record of 23 what's being said here today. Will you do that? 24 A. Yes. 25 Q. Okay. State your full name. CONTINENTAL COURT REPORTERS, INC. 5 1 A. Hunter Adrian Hammill. 2 Q. Dr. Hammill, I have before me what's been 3 marked as Hammill Deposition Exhibit 1, which is your 4 curriculum vitae. Is that your curriculum vitae? 5 A. It looks current. I have another one in a 6 little better print. But, yes, it looks current. 7 Q. And that's up to date as we sit here today? 8 A. To my understanding. Wait a second. I guess 9 I have a more current one, if you'd like to look at 10 that, which I'm happy to give to you. 11 Q. All right. Why don't we give that to the 12 court reporter, and we'll mark that one. 13 A. Okay. 14 Q. And that will be Hammill Exhibit 2, please. 15 (Exhibit No. 2 marked) 16 Q. Doctor, what is the definition of "fever" in a 17 postpartum patient? 18 A. Well, fever would be temperatures usually over 19 101, is the -- what's usually accepted. 20 Q. And that would included a single temperature 21 of over 101 within the first 24 hours after delivery? 22 A. Yes. Any temperature over 101 or greater 23 would be considered a fever. 24 Q. And do you know how long that has been the 25 accepted definition of "postpartum fever"? CONTINENTAL COURT REPORTERS, INC. 6 1 A. Well, it's been debated. I think the number 2 of 101 has been traditionally accepted for decades. 3 Q. Okay. And did that have anything to do with 4 the awareness or resurgence of any aggressive organism 5 such as staph or GAS or GBS -- 6 MR. BONEZZI: Objection; form. 7 Q. (By Mr. Paris) -- or was that -- did that 8 develop independent of those -- that phenomenon? 9 MR. BONEZZI: Objection to the form of 10 the question. 11 Go ahead and answer. 12 A. Okay. Could you just repeat the question so I 13 understand exactly what you're asking? 14 Q. (By Mr. Paris) Well, I was under the 15 impression that at one time one of the accepted 16 definitions of "fever" was anything -- a temperature 17 of 100.4 occurring in any 2 days of the first 10 days 18 post-delivery, excluding the first 24 hours, and so 19 long as that temperature is taken every 6 hours. 20 A. Some people have stated that. 21 Q. Okay. 22 A. Okay? That's your statement. What's the 23 question? 24 Q. The next question, is you've defined the 25 accepted definition of "fever" as a temperature in CONTINENTAL COURT REPORTERS, INC. 7 1 excess of 101? 2 A. 101 or greater. 3 Q. Or greater. 4 A. Yes. 5 Q. Okay. And what is the reason for the 6 disparity between those two definitions? 7 A. I would say that different people have 8 different opinions. 9 Q. Okay. Has -- did the definition of a 10 temperature of 101 or greater -- 11 A. Yes. 12 Q. -- grow out of any particular phenomenon or 13 any particular study? 14 A. I think the febrile morbidity in the 15 developing of a fever to that elevation associated with 16 an infectious etiology or an organic etiology is more 17 common than a temperature of a lower grade that may be 18 due to a reaction -- a low grade temperature just after, 19 say, running a marathon. 20 Q. In your papers that -- when you published on 21 this subject back in the late eighties and early 22 1990s -- 23 A. Yes. 24 Q. -- a temperature of 101 or greater was one of 25 the criteria that you utilized in determining whether CONTINENTAL COURT REPORTERS, INC. 8 1 there was postpartum infection, correct? 2 A. Yes, what we call febrile morbidity. 3 Q. Okay. And is it important in the first 24 4 hours after delivery to let a fever climb to see if it 5 stays in the so-called innocent range or climbs beyond 6 that innocent range? 7 A. I wouldn't choose the word "innocent." 8 I think the fever is one parameter of 9 many that is used to assess a patient. There are other 10 vital signs, what actually occurred prior to that 11 temperature elevation. For example, if a patient had an 12 abscess you drained and they had a fever, that puts it 13 in a different perspective. So there are many variables 14 that come into play, but temperature is one of them. 15 Q. Okay. And can a spiking fever within the 16 first 24 hours of delivery be an important sign or 17 symptom of a serious postpartum infection? 18 A. Yes. 19 MR. BONEZZI: Objection to the form of 20 the question. 21 Q. (By Mr. Paris) And will the use of 22 antipyretics such as Motrin or Tylenol with codeine 23 or continuous ice packs artificially suppress or 24 bring down a fever? 25 MR. JEFFERS: Objection. It's not CONTINENTAL COURT REPORTERS, INC. 9 1 fitting the fact pattern of this case when you use that 2 type -- that term relative to the ice pack. 3 Q. (By Mr. Paris) You may answer, Doctor. 4 A. I think that if a patient has a significant 5 fever due to an infection, the antipyretics and ice 6 packs may lower the temperature but the patient usually 7 breaks through those antipyretic efforts and will 8 re-spike. They will only keep it down transiently. 9 Q. When you say "transiently," is there a time 10 frame that you have in mind to a reasonable degree of 11 medical probability? 12 A. Two to three hours, or when the patient has 13 another septic event, which can be any time. 14 Q. When evaluating a patient for a potential 15 postpartum infection of the genital tract, is it 16 important for a physician to know if the fever is being 17 artificially suppressed with the use of antipyretics? 18 A. It's -- it would be important to know that. 19 Yes. 20 Q. What are the criteria, Doctor, for a genital 21 tract infection in the postpartum patient? 22 A. Well, I would want you to clarify that 23 question a little bit. When you say "postpartum," the 24 other variables, one of the big decisions, is it vaginal 25 delivery or was it an abdominal delivery, like a CONTINENTAL COURT REPORTERS, INC. 10 1 C section. Because the threshold of problems is higher 2 with one versus the other. 3 Q. Well, are there different criteria? I'm not 4 talking about risk factors; I'm talking about criteria. 5 A. I think there are different things you look 6 at. For example, if you had a C section, there's an 7 abdominal wound infection that needs to be evaluated. 8 If you have a vaginal -- and there's a uterine incision 9 that needs to evaluated. And there's bowel problems 10 that could occur that need to be evaluated. So there's 11 a whole layer of events, all that can be associated, not 12 uncommonly, with fevers -- 13 Q. To the extent -- 14 A. -- and infections. 15 Q. To the extent that there's overlap between the 16 two, the vaginal and C section, can you identify those 17 criteria? 18 A. The -- the overlap -- and I wouldn't even call 19 them "overlap." I often view them almost as -- as very 20 different entities we're talking about. The 21 similarities are the baby is born, the placenta is out, 22 there's no retained tissue; that would be one common 23 variable. 24 The other variable would be, what was the 25 labor pattern like? For example, did the patient have a CONTINENTAL COURT REPORTERS, INC. 11 1 fever or an infection before the delivery? Then the -- 2 such as tachycardia in the baby or the mother. Did she 3 have prolonged rupture of membranes? Were there 4 variables that would make me think there was a fever -- 5 an infection, an infection, not a fever. 6 So the common variables, I would say, 7 would be -- and they're not much overlapping. Uterine 8 tenderness, okay, fever, those are the clinical symptoms 9 on examining the patient. 10 Q. And what about lab values? 11 A. Lab values come into play. You'd look at the 12 CBC to see if there was excessive blood loss, suggesting 13 a hematoma someplace, which could head towards an 14 infection, and white count. 15 Q. Okay. In the studies or the articles that 16 you've written with Dr. Martens back in the late 17 eighties, early nineties, didn't you also look at as a 18 criteria for postpartum infection white blood counts 19 higher than 14,000? 20 A. Yes. 21 Q. Or greater than 15 percent in bands? 22 A. Yes. 23 Q. Okay. So that, too, would be a criteria? 24 A. Those were papers Dr. Martens wrote with me. 25 Okay. CONTINENTAL COURT REPORTERS, INC. 12 1 Q. The -- those are criteria that you used. Is 2 that correct? 3 A. There were many criterions usually sent by -- 4 set by the pharmaceutical company or the FDA that was 5 having a protocol that we were following when we did 6 studies and then later published the papers. 7 Q. You found those to be reasonable criteria, did 8 you not? 9 A. Reasonable criterion. Yes. 10 Q. Okay. You adopted those for purposes of your 11 studies? 12 A. Many times. 13 Q. Okay. Was the presence of nausea sometimes a 14 criteria? 15 A. Nausea, again, we get into one of these 16 overlapping areas. Because nausea per se is not a -- is 17 not a classic phenomenon, except in an abdominal 18 delivery where there's problem with the bowel, with an 19 ileus or a violation of the bowel or appendicitis. So, 20 again, we get into a different garden. But nausea is 21 associated with many phenomenon non-specifically. 22 Q. And these criteria that we're talking about, 23 these are criteria that you also adopt in your private 24 practice. Is that correct? 25 A. To understand your question, do I examine my CONTINENTAL COURT REPORTERS, INC. 13 1 patients and order appropriate lab tests and then assess 2 them? Yes. 3 Q. Well, I was being more specific. I was 4 talking about when you're -- when you're considering 5 postpartum infection, the fever, temperature that we 6 talked about, the lab values that we talked about -- 7 A. Yes. 8 Q. -- and the uterine tenderness -- 9 A. Yes. 10 Q. -- these are criteria that you also embrace in 11 your private practice? 12 A. Yes. 13 Q. Okay. What criteria do you accept for sepsis 14 in the postpartum patient? 15 A. Well, sepsis, again, it depends how you define 16 it. If that means you have a positive blood culture 17 with an organism growing, which you usually don't know 18 initially, then the patient is septic. 19 Q. Before you know that there's a organism? 20 A. There are symptoms associated with sepsis and 21 phenomenon such as you just respecified: White count, 22 fever, chills. And there can also be associated other 23 vital sign changes, such as hypotension, tachypnea, 24 tachycardia. 25 Q. When you say "hypotension" what do you mean? CONTINENTAL COURT REPORTERS, INC. 14 1 A. Blood pressure drops and the patient is 2 unresponsive. I mean, there are ranges of hypotension. 3 You have to look at the range. But if the patient is 4 systematically hypotensive, that's septic shock. 5 Q. I'm just talking -- is there a difference 6 between sepsis and septic shock? 7 A. I think there's a progression. 8 Q. Okay. Let's talk about -- 9 A. And the degree of the toleration of blood 10 pressure changes depends on other variables such as the 11 degree of the bacteremia. There are other factors that 12 come into play. Was the patient anemic to begin with? 13 Q. Well, I'm not at septic shock yet. I wanted 14 to -- 15 A. But also when you talk about blood pressure 16 dropping. 17 Q. I wanted to understand your criteria for 18 sepsis in the postpartum patient before they go to 19 septic shock. And if there's an early, mid, and late 20 stage, let's talk about those criteria, if you would. 21 A. Well, if you're trying to spectromize it -- 22 okay, this has been postulated by many people. 23 Difficulty with doing early, mid, late, 24 is we don't have the retrospective view. In that early 25 infection, might be a little tenderness, mild CONTINENTAL COURT REPORTERS, INC. 15 1 temperature elevation, a suspicion almost. Mid, the 2 patient might have a more elevated temperature, white 3 counts more elevated, and patient's more tender. Late, 4 the patient is in extreme -- is in more of extremeness. 5 There's an abscess; there's thrombosis. And those 6 patients may be heading towards surgery for debridement. 7 But the spectrum of that is always 8 somewhat speculative, almost, because we usually do not 9 open everyone's abdomen. As a matter of fact, in 10 obstetrics and gynecology, we violate that rule, unlike 11 with general surgeons, in that we don't always open and 12 drain the abscesses. So that's been discussed. 13 Q. You were -- you included in your criteria for 14 sepsis some vital signs, and I want to return to those 15 vital signs. You talked about hypotension. And are you 16 comfortable giving me a range of the blood pressures 17 that would be consistent with a progression into sepsis? 18 A. I think, again, patients have to be 19 individualized. If you had a hypertensive patient and 20 their pressure dropped to a normal range, that would be 21 a hypotensive phenomenon relative to that patient. If 22 you had an athlete, like a marathon runner, you would -- 23 they may have an athletic heart and chronically run a 24 low blood pressure with the diastolic in the 50s. So I 25 think it's a relative decision within those ranges. CONTINENTAL COURT REPORTERS, INC. 16 1 Q. What about a patient like Beth Williams? 2 A. I think if a patient had a diastolic pressure 3 that dropped, where all the other vital signs are 4 dropping, diastolic goes below 40, they are having a 5 rapid heart rate, trouble breathing, you know, this is 6 consistent with a picture of sepsis, clearly. 7 Q. Let's talk about the elevated heart rate in a 8 patient like Beth. What -- what heart rate would you 9 expect to see in that progression into sepsis? 10 A. Now, are you asking me about this patient 11 specifically, since you worded it that way? 12 Q. Sure. 13 A. I think this particular patient, due to the 14 toxin that was released, there's a toxin cascade, and -- 15 which leads to death. And eventually the blood pressure 16 drops and the pulse goes up and the heart rate goes up 17 and the respiratory rate goes up and they die. 18 Q. What's a normal heart rate for a healthy 19 patient like Beth? 20 A. A healthy patient, a normal heart rate? 21 Q. Yeah. 22 A. Would be probably anywhere from 50 to -- if 23 she was anxious after delivery or in a lot of pain, you 24 could see heart rates up to 120. It depends what's 25 going on in the clinical setting. But certainly an CONTINENTAL COURT REPORTERS, INC. 17 1 elevated heart rate is a sign of a problem, as well as a 2 very low heart rate. 3 Q. As a general proposition, are heart rates over 4 a hundred in a normal pregnancy considered to be 5 elevated? 6 A. I think heart rates of a hundred would be 7 elevated in the mother. However, if a woman's pushing, 8 sometimes you have heart rates elevated. If their 9 ex-husband walks in the room, their heart rate goes up. 10 So there are other variables you have to put into play. 11 Q. Respiration rate in a normal healthy 12 postpartum patient? 13 A. Respiration, normally is anywhere from 16 to 14 30. Thirty's really upper limit, I'd say, as far as 15 being rapid. I think once the respiratory rate goes 16 over 30, they are having trouble breathing. 17 Q. Now, what are the criteria of septic shock in 18 a postpartum patient? 19 A. Well, septic shock, the patient's vital signs 20 change to a point where they're not there or are not 21 compatible with life. They go into shock; they 22 vasoconstrict. The body is trying to save itself by 23 shunting blood to vital organs -- the heart, the lungs, 24 the brain -- and the patient becomes somewhat 25 devascularized. And eventually the blood pressure CONTINENTAL COURT REPORTERS, INC. 18 1 continues to fall and the body can't stand what's going 2 on and you die. 3 Q. Are there generally accepted criteria, talking 4 about vital signs, blood pressures, that you accept as a 5 patient going into septic shock? 6 A. I think what I have to do is what I do with 7 all patients. I don't take just one isolated vital 8 sign. If you had hypertension and you were 9 hypertensive, you know, the other thing. So I look at 10 all four vital signs: The blood pressure, the pulse, 11 the respirations, the temperature. And, certainly, if 12 they are all trending in an ominous nature, patient's 13 having a rapid heart rate, let's say over 120, certainly 14 is ominous. Their respiratory rate is going above 30, 15 their temperatures are rising -- although sometimes 16 patients can have cold sepsis and not have a fever -- 17 and then their blood pressure may transiently elevate, 18 but it usually drops as a bottoming-out phenomenon. And 19 all those things combined and the heart stops pumping. 20 Q. Is there a different criteria for Group A 21 Strep Toxic Shock Syndrome than the one that you just 22 described? 23 A. Not that I'm aware of. Shock is shock. Shock 24 is very simply defined, and its sequelae are very clear. 25 Q. Do you have experience with strep A CONTINENTAL COURT REPORTERS, INC. 19 1 infections? 2 A. Yes, I do. Limited. 3 Q. With what frequency have you made that 4 diagnosis yourself? 5 A. Well, I would say there are probably two Group 6 A strep deaths and shock related to postpartum 7 infections a year in the United States. And I work at 8 the largest medical center in the world, at one time was 9 in a system that supervised 40,000 deliveries a year. 10 In the last 10 years, I probably have seen one case. 11 Q. In the last how many? 12 A. Ten years. 13 Q. Okay. 14 A. Although -- and I will qualify that -- I work 15 in a system where a large part of the population of this 16 country is born. It is an infrequent phenomenon. And I 17 will qualify that by saying Group A strep is recovered, 18 not just where it's postulated. And where the toxin's 19 released in the patient as an untoward outcome. So -- 20 and I don't think anyone has seen hundreds of cases. 21 Q. Just so I'm clear on the number, your number 22 is one? 23 A. Yes. 24 MR. BONEZZI: In the last 10 years. 25 A. Last 10 years, verified Group A strep. CONTINENTAL COURT REPORTERS, INC. 20 1 Q. (By Mr. Paris) Yeah. How about before 2 1991? 3 A. I might have seen one other case. I mean, it 4 is an uncommon phenomenon. Very uncommon. 5 Q. And were you a consultant on both of those 6 cases? 7 A. In those situations, I was working at a large 8 county hospital where everybody in shock we thought they 9 were septic, I or my partner was called in. So we 10 either were the consul -- we -- usually, yes, we were 11 the consultants. But we were also in charge of running 12 the postpartum services. Or once the delivery occurred, 13 we managed all the complicated patients and then we 14 became the primary caregiver. 15 Q. Okay. Are you of the opinion that Group A 16 strep infections postpartum are treatable and curable? 17 A. Well, again, I think you have to qualify that 18 question. Because there is Group A strep infections, 19 just like there are methicillin resistant staph 20 infections. But if you're talking about do I believe 21 once toxin-producing Group A strep infections occur and 22 release the toxin in postpartum infections, they are 23 unpredictable, they are rare -- and I can't say a 24 hundred percent -- but in my experience are a hundred 25 percent fatal and the experience of all the colleagues CONTINENTAL COURT REPORTERS, INC. 21 1 that I've worked with. 2 So I'm not saying a Group A strep 3 organism that's cultured from an abscess maybe and the 4 toxin's not released. Those are radically different 5 phenomenon. And why the toxins are released in some 6 versus not is still, in my opinion, an act of God that's 7 not been established. 8 Q. I take it you're pretty familiar with the 9 morbidity and mortality with postpartum infections? 10 A. I work in a large system, have dealt on the 11 largest obstetrical service in the country, and define 12 many of the criterion you quoted in the societies, in 13 groups I belong to. So if in your opinion that makes me 14 an expert, that's fine. That's -- all I can tell you is 15 my experience, which is -- 16 Q. Can you tell me in your experience the 17 frequency of postpartum infections in a C section 18 setting? 19 A. Absolutely. 20 MR. BONEZZI: Objection. 21 Go ahead. 22 A. Okay. I would say that prior to antibiotic 23 prophylactics -- and, again, this is not a simple 24 question -- because there are sections that are done 25 electively, and then there are sections that are done CONTINENTAL COURT REPORTERS, INC. 22 1 when patients have been in labor with ruptured 2 membranes. Those are almost two different entities, and 3 the febrile morbidity, which I'm using as opposed to 4 clear infection, are different, are like apples and 5 oranges. 6 And then there's vaginal deliveries. The 7 incidence in services in repeat elective C sections with 8 unruptured membranes where prophylactic antibiotics are 9 given can be less than 10 percent. In settings where 10 prophylactic antibiotics are not given and the patient's 11 been in labor, febrile morbidity and presumed infections 12 can be as high as 30 percent in some series at large 13 county hospitals. 14 If you look at vaginal deliveries, 15 febrile delivery is usually less -- is usually in the 16 1 percent range. It's low. 17 Q. (By Mr. Paris) And the frequency of 18 postpartum infections that develop into sepsis? 19 A. Again, that is a difficult figure to answer, 20 since usually blood cultures are not taken at the time 21 of bacteremia. But, again, that number I would put at 22 less -- I will qualify that by saying where an organism 23 is recovered, would be less than 10 percent, but that is 24 overall taking everybody. 25 Q. Okay. And what about -- CONTINENTAL COURT REPORTERS, INC. 23 1 A. So the yield is low. But when it's positive, 2 it's significant. 3 Q. What about the frequency of postpartum 4 infections that develop into GAS? 5 A. Could you define what you're just -- 6 Q. Group A strep. 7 A. Group A streptococcus? 8 Q. Yes. 9 A. Okay. I would say, again, Group A 10 streptococcus, in my experience, there are probably 11 about two cases a year that result in death in the 12 United States. So this is a rare phenomenon, an 13 unpredictable phenomenon, why the toxin is released. 14 Q. And -- but in GAS postpartum infections, 15 toxins are not always released. Is that what you're 16 saying? 17 A. What I'm -- what I'm saying is -- yes. And 18 what usually happens is Group A strep can even be 19 cultured as an incidental finding and not result in any 20 infection. Just like there might be someone in this 21 room with Group A strep in their body somewhere -- and 22 we're talking giving this deposition -- no one's in 23 sepsis or shock. 24 Q. It's your opinion, then, that in those 25 postpartum infections that develop into GAS when toxins CONTINENTAL COURT REPORTERS, INC. 24 1 are released, a hundred percent or nearly a hundred 2 percent of the patients will die? 3 A. Yes. 4 Q. People don't survive it? 5 A. People don't survive. 6 Q. Okay. And it is the toxins that -- that cause 7 this cascade into sepsis and septic shock? 8 A. I've stood at the bedside of many patients, 9 not where Group A strep was always isolated or an 10 unknown organism results, they develop what's called the 11 Pink Lady Syndrome. They go into DIC, they stop 12 breathing, and they die. Yes, it is my opinion. 13 Q. And is that something that's called 14 Streptococcal Toxic Shock Syndrome? 15 A. Well, I'd be a purist because I work with 16 Toxic Shock Syndrome. Some people may have used that 17 terminology. Pure Toxic Shock Syndrome involves the 18 staph aureus with a toxin produced by that isolate. So 19 you could use that expression. But I think in the 20 parlance when people speak of TSS, they are really more 21 concerned -- they tend to talk about the pure Toxic 22 Shock Syndrome that was reported about 20 years ago 23 mainly out of southern California with a different 24 organism. But if you want to use that expression, I 25 understand what you're saying. CONTINENTAL COURT REPORTERS, INC. 25 1 Q. I've read it somewhere. That's why I'm using 2 it. 3 A. Okay. 4 Q. I want to know if that's a -- if that's a term 5 of art, something that you accept. 6 A. The toxin's released, and it's released from 7 Group A strep. That's how I'd word it. I wouldn't use 8 Group A strep TSS, because TSS in the history, being an 9 historical person, has more of a connotation of the 10 staph aureus TSS associated with tampons and lawyers and 11 other things. So I don't use that term. 12 Q. When you provided us with the statistic that 13 once the Group A strep toxins are released, there is a 14 hundred percent or nearly 100 percent likelihood of 15 death? 16 A. Yes. 17 Q. As -- can you point to any studies to support 18 that? 19 A. Well, I report the classic study written by 20 Ignat Semilice (sic) in the 1800s where they had an 21 upwards of 20 percent maternal death rate, and that 22 organism was felt to be Group A strep. That's -- that 23 is the pioneer in obstetrics and gynecology infections, 24 the founder of statistics in this area. And that is 25 probably -- that was before Pasteur. That is probably CONTINENTAL COURT REPORTERS, INC. 26 1 the best example I could give you. 2 Q. Is there anything more current than the 1800s? 3 A. Oh, yeah. I think if you look at textbooks -- 4 and I didn't look at textbooks -- but if you look at -- 5 or even ask any other infectious disease people that I 6 work with, because when we have maternal deaths from 7 sepsis, we discuss them. And I'm not aware of anybody 8 who's taken care of a Group A strep, toxin-producing 9 patient who's lived. And when I talk to people at the 10 CDC, which I haven't done recently, we haven't had 11 survivals reported. And they base that on the fact that 12 they have the organism, they isolate the toxin, and they 13 die, even much like the Toxic Shock Syndrome you 14 described where they save the organisms to see if some 15 new virulent strain is evolving. 16 Q. Is there any literature or have you conducted 17 any studies that support that statement, that a hundred 18 percent of the patients who have GAS toxins released 19 will die? 20 A. Well, I haven't done a study on that group for 21 the obvious reason it's so rare. And I don't think 22 there is a good study because it's so rare. I think in 23 the -- if you're going to be a purist about this, where 24 they have the organism, they have a toxin phenomenon, 25 those patients in all the reports that I've read, die. CONTINENTAL COURT REPORTERS, INC. 27 1 And that's a cumulative from 20 years as a -- in 2 infectious disease as an OB-GYN. 3 And the case reports where the patient 4 lived, they either didn't have the organism or they 5 didn't isolate the toxin. And as a scientist, it was a 6 suggestion and not proven. You've got to have those 7 criterion. And maybe they're my criterion. Got to have 8 evidence of the toxin isolated from the patient, got to 9 have the toxin produced by that organism, and you got to 10 have that organism recovered from the patient. 11 Q. You've got to have the toxin serotyped? 12 A. Well, not necessarily. But if the pa -- if 13 you're going to publish a paper for the world's 14 literature as a standard of care, you have to adhere to 15 a higher standard, if you will, to postulate that this 16 is definitely, you know, the large series. And I'm not 17 aware of any large series because it's such a rare 18 phenomenon. 19 Q. Okay. Just switching gears for a second. 20 With regard to the nature of your practice, what 21 percentage of your time is involved in obstetrics and 22 what percentage is in gynecology? 23 A. I would probably say at least 70 to 80 percent 24 obstetrics and 20 to 30 percent gynecology. 25 Q. And to what extent does the infectious disease CONTINENTAL COURT REPORTERS, INC. 28 1 aspect of your background enter into your practice? 2 A. Probably about 70 percent of my patients 3 have -- are seeing me for OB-GYN. However, they have an 4 infection either as part of their chronic problems, 5 which is why they've been referred to me, such as AIDS, 6 and they are pregnant or --- excuse me -- where they 7 have a, you know, postpartum infection, one of these 8 unusual consultation events. 9 Q. Do you personally know any of the defendants 10 in this case, Dr. -- 11 A. Yes, sir. Oh, the defendants? No. 12 Q. Do you know Dr. Hahn? 13 A. No. Not that I'm aware of. 14 Q. Do you know Nurse Prokop or Nurse Bazzo or 15 Nurse Hulvilchick? 16 A. No. 17 Q. All right. Let's talk about the defense 18 experts. Do you know David Soper? 19 A. Yes. 20 Q. How do you know David? 21 A. David was -- when I was a fellow in infectious 22 diseases in -- at UCLA, Dr. Soper was starting his 23 fellowship when I was finishing mine, and we actually 24 collaborated in discussions and some work when he was 25 employed by the United States Navy. CONTINENTAL COURT REPORTERS, INC. 29 1 Q. You two still belong to the same societies? 2 A. Yes, at least some of them maybe. I don't 3 know if he belongs to the same ones I do, but I consider 4 Dr. Soper a colleague and a friend. 5 Q. Okay. Do you know Dr. Method Duchon? 6 A. Method Duchon, yes, I do. He was on the 7 faculty at Case Western, and I know Dr. Duchon from when 8 I was at -- in Cleveland. 9 Q. Do you know Dr. Martin Raff? 10 A. No. Not that I'm aware of. 11 Q. Do you know Dr. Keith Armitage? 12 A. Not that I'm aware of. 13 Q. Do you know Dr. Robert Flora? 14 A. No. 15 Q. Do you know any of the plaintiff's expert 16 witnesses, Richard Sweet? 17 A. I know Dr. Sweet. 18 Q. How do you know Dr. Sweet? 19 A. Dr. Sweet has long been doing work in 20 infectious diseases from when he was at the University 21 of San Francisco. And I've met him at meetings, you 22 know, in infectious diseases. It's a small group of 23 people that work in OB-GYN infectious diseases. 24 Q. When you -- 25 MR. BONEZZI: Excuse me for a point of CONTINENTAL COURT REPORTERS, INC. 30 1 clarification. It's my understanding that Richard Sweet 2 has been one of the plaintiff's experts. That's at 3 least a letter that I received or something orally was 4 presented to me. 5 MR. SCHOBERT: As it pertains, at least, 6 to the June 25th trial date. 7 MR. PARIS: Yeah. That's correct. 8 MR. BONEZZI: That's fine. I apologize 9 for interrupting. 10 Q. (By Mr. Paris) In some of the papers that 11 you published with Dr. Martens, did you cite 12 Dr. Sweet in your -- in your papers? 13 A. You mean in the references in the papers? 14 Q. Yes. 15 A. I would not be surprised if there was a 16 reference to an article Dr. Sweet wrote. 17 Q. Is he generally recognized to be a reliable 18 authority in the area that you practice? 19 A. I've never worked with him clinically, so I 20 can't comment about his clinical practice. I've only, 21 you know, you know, met him at meetings and read his 22 papers. 23 Q. Did you find his papers to be reliable? 24 A. On occasion. 25 Q. On occasion you didn't? CONTINENTAL COURT REPORTERS, INC. 31 1 A. On occasion I didn't. 2 Q. Okay. How about Dr. Mark Martens? I take it 3 you know him? 4 A. Dr. Martens was finishing his fellowship when 5 I arrived, and he was here for about a year before he 6 left. And I've known him, again, at meetings since 7 then. 8 Q. Did you apply for Dr. Martens' job? 9 A. Not at all. 10 Q. Were you offered his job after he left? 11 A. Absolutely not. There's no relationship. 12 True, true unrelated. 13 Q. Okay. 14 A. I was recruited by Dr. Farrow, specifically as 15 a senior infectious disease person. And Dr. Martens was 16 finishing his fellowship, leaving. 17 Q. Okay. You find Dr. Martens to be a reliable 18 authority on the subject of GAS? 19 MR. BONEZZI: Objection. 20 Go ahead and answer. 21 A. Not from what I read in his deposition. 22 Q. (By Mr. Paris) Okay. Do you know Martin 23 Gimovsky? 24 A. Martin who? 25 Q. Gimovsky. CONTINENTAL COURT REPORTERS, INC. 32 1 A. No. 2 Q. Neil Crane? 3 A. No. 4 Q. And the nurse, Helen Marie Waters? 5 A. No. 6 Q. Did you yourself review any articles or text 7 regarding any of the issues involved in this case? 8 A. No. 9 Q. Have you read any articles or book chapters 10 authored by any expert in this case that deals with 11 issues relevant to Beth Williams? 12 A. May I -- I may have during my life, but not 13 that I recall, you know, related to this case. 14 Q. Do you believe any of the experts that I've 15 just mentioned are reliable authorities on the subject 16 of recognition and treatment of postpartum infections? 17 MR. BONEZZI: Objection. 18 MR. JEFFERS: Objection, too. 19 A. I'll answer that question this way, which I do 20 many times when people bring in a vacuum question, 21 usually at a grand rounds or something. 22 The person who has the best ability to 23 evaluate a postpartum infection is the physician who has 24 the privilege to be at the bedside. So I can quote 25 references; we discuss standards. But in order to CONTINENTAL COURT REPORTERS, INC. 33 1 evaluate a postpartum fever in a patient, you have to 2 see the patient. And short of that, we're in a vacuum. 3 Q. (By Mr. Paris) I agree. Do you believe -- 4 A. I say that as a physician. 5 Q. And what is the benefit of being at the 6 patient's bedside if you don't have a -- 7 A. Well, let's put it this way. The gentleman 8 sitting next to me is saying nothing. He could be 9 voicing no complaints or he could be in coma. That's 10 the difference. 11 MR. JEFFERS: Usually. 12 MR. BONEZZI: We can take a vote. 13 A. I don't mean to make light of the seriousness 14 of this case. But I want to accentuate the ability and 15 the -- and the extreme situations where sometimes I've 16 seen patients that were advertised as voiced no 17 complaints but were in coma. 18 Q. (By Mr. Paris) Have you authored any -- 19 VIDEOGRAPHER: Wait one minute. I think 20 his -- 21 MR. PARIS: Oh, your -- 22 THE WITNESS: I missed my best part of 23 this. 24 MR. JEFFERS: Did you pick that up? 25 VIDEOGRAPHER: Yes. CONTINENTAL COURT REPORTERS, INC. 34 1 THE WITNESS: I'm sorry. 2 MR. JEFFERS: I probably stepped on it 3 being a klutz and pulled it off. 4 Q. (By Mr. Paris) Have you authored any 5 articles or book chapters that deal with issues 6 relevant to Beth's case? 7 A. I've written articles -- that I've written 8 articles with Dr. Martens even about postpartum 9 endometritis, and I've written a chapter about wound 10 infections after surgery. So I have several articles 11 that address endometritis that address -- because, as a 12 matter of fact, the majority of my CV, excluding the 13 AIDS patients and vaginitis, are about infections in 14 obstetrics. 15 Q. Do you believe your articles to be reliable 16 authorities? 17 A. I think my articles are written in a time 18 frame at the time they were written. Antibiotics 19 change. I think they're the truth as best as I could 20 express them. Yes. 21 Q. The last time you authored anything on that 22 subject was in the early 1990s? 23 A. Yes. The majority of my work has been 24 consumed with the global epidemic of AIDS. 25 Q. Right. CONTINENTAL COURT REPORTERS, INC. 35 1 A. Although, I have worked with several authors 2 involving, most recently, C section morbidity involving 3 AIDS patients which were even, in theory, a higher risk 4 group. So I guess you could say about a year and a half 5 ago I wrote about C section morbidity, and if that -- 6 and postpartum morbidity, if this relates to this case. 7 But... 8 Q. You devote 50 percent or more of your 9 professional time of the act of clinical practice and 10 are teaching in your field? 11 A. Practice or teaching? 12 Q. Yeah. 13 A. Ninety-nine percent of the time I spend taking 14 care of patients. 15 Q. Okay. What do you do the other 1 percent of 16 the time? 17 A. Paperwork for HMO's. 18 Q. Okay. And you're licensed to practice in -- 19 A. Ohio -- 20 Q. Texas? 21 A. -- Texas, and California. 22 Q. You've been involved in the litigation 23 experience for -- for some time? 24 MR. BONEZZI: Objection to the form. 25 Go ahead and answer. CONTINENTAL COURT REPORTERS, INC. 36 1 A. I usually have about anywhere from two to five 2 cases a year referred to me. I also -- about six years 3 ago was also involved in the adolescent pediatric 4 gynecology area. And, unfortunately, was involved in 5 usually criminal litigation involving abuse and other 6 matters, so I've testified in those settings. I've also 7 testified in malpractice cases, although that's not 8 common. 9 Q. (By Mr. Paris) How many years have you 10 been consulting as an expert witness? 11 A. I would say probably anywhere from 15 -- 15 to 12 20 years maybe, in that range. People have asked me 13 legal questions infrequently. 14 Q. Have you consulted with any of the lawyers or 15 law firms involving this case? 16 A. Not that I'm aware of, although I know I was 17 involved in a case in Cleveland, and I don't know if the 18 lawyers here were involved in that case. 19 Q. Was that the law firm of Jacobson, Maynard, 20 Cushman, & Taylor? 21 A. I'd have to look. I remember what the case 22 was about. 23 Q. You do remember what the case was about? 24 A. Yeah. 25 Q. What was it about? CONTINENTAL COURT REPORTERS, INC. 37 1 A. Varicella and pneumonia. 2 Q. Did that go to trial? 3 A. Yes, it did. 4 Q. And you testified live at trial? 5 A. Yes, I did. 6 Q. I take it you've never been consulted with the 7 Nurenberg, Plevin law firm? That would be my law firm. 8 A. I'm familiar with the Nuremberg laws with 9 regarding the experimentation. But, no, not that I'm 10 aware of. 11 Q. What percentage of your cases do you consult 12 with are for the plaintiff and what for the defense? 13 A. I'd say probably three-quarters for the -- by 14 "plaintiff," who do you find -- is that the doctor? 15 Q. The patient. 16 A. The patient. Probably at least 25 percent of 17 the time is with the patient. 18 Q. And the other 75 percent for the medical care 19 provider? Yes? 20 A. Yes. 21 Q. Do you have a file with regard to this case? 22 A. Yes, I do. And I have it. I'm sitting on top 23 of it. 24 Q. All right. Let's go off the record a minute. 25 VIDEOGRAPHER: Off the record at CONTINENTAL COURT REPORTERS, INC. 38 1 2:53 p.m. 2 (Recess from 2:53 p.m. to 2:55 p.m.) 3 VIDEOGRAPHER: On the record at 2:55 p.m. 4 Q. (By Mr. Paris) Doctor, I take it that you 5 were provided with a number of materials that you 6 reviewed that allowed you to arrive at certain 7 opinions in this case. Is that correct? 8 A. Yes. 9 Q. And the opinions that you arrived at in this 10 case were expressed in an expert report that you 11 authored and forwarded to "To Whom it May Concern"? 12 A. Right. 13 Q. Which I guess would be Mr. Bonezzi? 14 A. Yes. 15 Q. Let's go through the materials that you've 16 reviewed initially in order to prepare your report and 17 the materials that you reviewed after you prepared your 18 report. I take it that you had an opportunity to look 19 through the entire Parma Hospital confinement record? 20 A. Yes. 21 Q. Okay. You had an opportunity to review the 22 University Hospital record -- 23 A. Yes -- 24 Q. -- where she died? 25 A. Yes. CONTINENTAL COURT REPORTERS, INC. 39 1 Q. You had you an opportunity to review the 2 prenatal records of Woman and Wellness? 3 A. Yes. 4 Q. Did you review any other records prior to the 5 preparation of your report? 6 A. I think that -- I think -- I believe that was 7 it. 8 Q. Okay. After you prepared your report, you 9 reviewed two depositions? 10 A. Yeah. Those -- yes, I did. 11 Q. That would be Dr. Mark Martens -- 12 A. Yes. 13 Q. -- and Dr. Neil Crane, two of the plaintiff's 14 experts? 15 A. Yes. 16 Q. At no time before you -- 17 A. And I was sent two copies of the depositions. 18 Q. Correct. 19 Did you ever review or ask for the 20 depositions of Dr. -- strike that. 21 Did you review the autopsy? 22 A. There's a -- there's a -- I believe there's an 23 autopsy report in here. 24 MR. BONEZZI: There is. 25 MR. PARIS: Okay. That's fine. CONTINENTAL COURT REPORTERS, INC. 40 1 MR. BONEZZI: It's part of one -- 2 MR. PARIS: I believe you. 3 Q. (By Mr. Paris) And the death certificate? 4 A. I'd have to look specifically if I saw the 5 exact death certificate. 6 Q. Did you review the depositions of Dr. Hahn? 7 A. I don't believe they're... 8 MR. BONEZZI: I haven't sent them yet. 9 Q. (By Mr. Paris) Did you ask for to review 10 the depositions of Dr. Hahn? 11 A. No. 12 Q. Did you review the deposition of Dr. Shah, the 13 house officer? 14 A. No. 15 Q. Did you ask for them? 16 A. No. 17 Q. Did you review the deposition of Paulette 18 Prokop? 19 A. No. 20 Q. I take it from the record that you were able 21 to ascertain that Nurse Prokop was -- was the nurse 22 taking care of this patient, right? 23 A. I'd have to look specifically, but I trust 24 that's the case, to verify the name. 25 Q. You didn't ask for her deposition, either? CONTINENTAL COURT REPORTERS, INC. 41 1 A. No. 2 Q. Same question as it relates to Nurse Bazzo and 3 Nurse Hulvilchick? 4 A. Correct. 5 Q. You didn't review -- 6 A. Same answer. 7 Q. -- and you didn't ask for them? 8 A. Yes. 9 Q. Okay. Did you ask for Dr. Crane and 10 Dr. Martens' depositions? 11 A. No. 12 Q. Did you review any of the deposition exhibits? 13 A. Yes, I did. Dr. Crane and Dr. Martens. 14 Q. No. The deposition exhibits taken during 15 Dr. Hahn's and Dr. Shah's depositions? 16 A. No, I did not. 17 MR. BONEZZI: Those exhibits would have 18 been part of the medical record, so the answer would be 19 yes, but he didn't read them independently. 20 A. I -- be more specific. 21 Q. (By Mr. Paris) Okay. Those exhibits which 22 relate to the duties of a house officer of Parma 23 Hospital -- 24 A. No. 25 Q. -- and the agreements between the house CONTINENTAL COURT REPORTERS, INC. 42 1 officer and the hospital, I take it -- 2 A. No. I didn't review those. 3 Q. Did you perform any independent research after 4 you obtained these materials for review? 5 A. No. 6 Q. And did you have any discussions with any 7 other physicians after you reviewed -- received these 8 materials, but before you authored your report? 9 A. No. 10 Q. Did you make any notes in the margins of any 11 of these records or elsewhere on a separate sheet of 12 paper why you were reviewing it and before you authored 13 your report? 14 A. You mean on the hospital records? 15 Q. Yeah. 16 A. No. No. I don't know if I left the folds in 17 the papers. But, no, I did not. 18 Q. And you have a copy of your expert report, do 19 you not? 20 A. Yes. There's one right next to me, I believe. 21 Q. Okay. And what is the date that you authored 22 that? 23 A. April 11th, 2001. 24 Q. And was that your first and only report? 25 A. Yes. CONTINENTAL COURT REPORTERS, INC. 43 1 Q. And in your report, essentially, you opined 2 that you believe the standard of care was met in this 3 case? 4 A. What do you mean by "opined"? How are you 5 using that? 6 Q. Well, I can only say it this way. In your 7 professional opinion, was it -- 8 A. I gave my professional opinion. 9 Q. -- was it not that the standard of care was 10 met in this case? 11 A. Yes, it was. 12 Q. And is it your professional opinion that the 13 accepted standard of medical care was met by each of 14 Beth's medical care providers? 15 A. I don't know if I could -- not having seen 16 some of the other depositions, from what I've reviewed, 17 this particular case, the outcome would be unchanged, 18 and I saw no standard of care deviation which would have 19 changed the outcome in this case. 20 Q. Well -- 21 A. So to answer your question, yes, it met the 22 standard of care. 23 Q. Okay. The care that was given to this woman 24 met the standard of care? 25 A. I would even go further and say I was very CONTINENTAL COURT REPORTERS, INC. 44 1 impressed that when the patient had a temperature and 2 any problem, a house -- a physician saw the patient, 3 which is not what I normally see, even at the medical 4 center I work at. 5 Q. I promise I'm going to go into the details of 6 each event, but right now I want to focus on your 7 report. 8 A. Yes. 9 Q. In your report, it was your opinion that the 10 standard -- accepted standard of care was met -- 11 A. Yes. 12 Q. -- with regard to this patient -- 13 A. Yes. 14 Q. -- No. 1? 15 A. Yes. 16 Q. And, No. 2, her death was unpreventable? 17 A. Yes. 18 Q. Okay. Can you summarize briefly for me, if 19 you can -- and if this is not a fair question, tell 20 me -- what you understand the facts to be in this case. 21 A. Okay. Can I just put this stuff down here? 22 Q. Sure. 23 A. And I'm not going to give the exact dates and 24 times because I'd have to look at the chart to give the 25 specifics, but -- CONTINENTAL COURT REPORTERS, INC. 45 1 Q. Give me an overview. 2 A. -- to give you the gestalt of this. 3 This is a patient that had some stigmata 4 of pregnancy-induced hypertension. Her delivery was 5 expedited and she delivered with a vacuum extractor, as 6 I recall, but delivered vaginally. And the delivery was 7 relatively uneventful. 8 After the delivery, the patient did 9 develop some shakes and a fever and was evaluated and 10 felt not to -- and, actually, the case is far more 11 complicated because the possibility of having 12 pregnancy-induced hypertension or eclampsia afterward 13 with seizures is not that uncommon, and that's what the 14 doctors were evaluating initially. 15 She had a fever within that first 12 16 hours post-delivery. And I would use the word "febrile 17 morbidity" was assessed not to be clinically septic at 18 the time. 19 And then within the next 24 hours, the 20 patient decompensated, consultants were called in, 21 appropriately, antibiotics were started. The patient 22 was sent to a tertiary care level due to her more 23 intensive care needs, and then subsequently was -- died. 24 Now, what I also find exceptionally 25 important in the fact is that Group A strep was CONTINENTAL COURT REPORTERS, INC. 46 1 cultured. And, in my opinion, the Group A strep with 2 its toxin release -- which is unpredictable, extremely 3 rare, and not preventable, unless you could have known 4 before she was in labor, before she was pregnant, and 5 even, you know, if you had a crystal ball. The patient 6 died. Why this particular patient had a toxin release, 7 I don't know. Why -- and my opinion is once the toxin's 8 released, the antibiotics don't help. And the patient 9 had a rapid course, which is associated with a toxin 10 releasing organism, and death. 11 Q. It's your opinion that Beth died from what 12 disease? 13 A. Beth died, in my opinion, from a toxin that 14 was released from Group A streptococcus. 15 Q. And what was the cause of the GAS infection? 16 MR. JEFFERS: Wait. Say that once more. 17 Q. (By Mr. Paris) What was the cause of the 18 Group A strep infection? 19 MR. BONEZZI: Objection. 20 Go ahead and answer. 21 A. Well, Group A strep may have been colonized in 22 her body. What triggered the release of the toxin is 23 the unknown. You know, someone might say if she had 24 never gotten pregnant and gone through birth, she 25 wouldn't have died. So why, I don't know. CONTINENTAL COURT REPORTERS, INC. 47 1 Q. (By Mr. Paris) Well, probability is that 2 the -- the Group A strep bacteria colonized during 3 childbirth, during labor? 4 A. Well, "colonized" is the -- is a word I'd have 5 to define. I assume the organism was in the vagina, in 6 her lower genital tract. Labor is not a sterile 7 process. The membranes rupture before birth. It's not 8 uncommon to culture organisms. And this -- there's only 9 a few centimeters from the vaginal vault to the apex of 10 the uterus. And whether the organism got in the 11 bloodstream due to the raw area that occurs when the 12 placenta separates, I don't know. That would be 13 speculation. But, certainly, it got into the deep 14 tissues of the uterus. Again, exceptionally uncommon 15 after a vaginal delivery because there was no scar on 16 the uterus. And whatever host bacteria phenomenon 17 occurred in her, it got into her uterus, the toxin was 18 released, and the rest is history. 19 Q. And is it your opinion that in all probability 20 the bacteria ascended from the vaginal canal into the 21 uterus after the membranes ruptured? 22 A. Well, it's sort of like asking me do I think 23 the bacteria got into the lungs when you took a breath. 24 Yes. They ascended some way. I do not believe that the 25 bacteria transmigrated the amniotic fluid, since she had CONTINENTAL COURT REPORTERS, INC. 48 1 no -- amniotic membranes, since she had no evidence of 2 infection prior to that. 3 Q. Would the -- in your opinion, is it probable 4 that this organism ascended into the uterus before 5 childbirth or after childbirth? 6 A. I have no way to say that. That would be a 7 complete speculation. 8 Q. Okay. Once this organism arrived in the 9 uterus, what happened? What probability? 10 A. Whether there was some issue that was 11 devascularized just from the normal birth with the 12 placenta separating and that one organism out of 13 thousands colonized there and whatever environment 14 triggers toxin release occurred and the toxin was 15 released in the bloodstream, not even necessarily having 16 to have a bacteremia, once the toxin gets in the 17 bloodstream. 18 Q. Retrospectively, when in your opinion did the 19 infection first begin? 20 A. Well, as you were trying to allude to, you 21 know, it could have occurred at birth. Now, when the 22 infection established itself, when that one organism 23 multiplied to a level where it could -- and then 24 whatever unknown trigger causes certain patients in 25 their host setting to release the toxin; in others, I CONTINENTAL COURT REPORTERS, INC. 49 1 don't know. 2 Q. Do you know when the infection first 3 manifested itself? 4 A. I can speculate that if one went backwards, 5 the toxin-producing phenomenon could have occurred when 6 she felt the shakes, when she had her fever. I mean, it 7 could have occurred at any time in the spectrum from 8 birth and even when they said the nurse brought the 9 baby, as I recall -- and I don't know the page -- wasn't 10 as interested in her baby, the toxin could have been 11 released. All I know is from the time of her birth to 12 the point of her death, at some time in between the 13 toxin was released, and she had a rapid downward course 14 once an inoculum was large enough. 15 MR. BONEZZI: In that question were you 16 equating "infection" to "toxin release"? 17 MR. PARIS: No. 18 MR. BONEZZI: Because there's -- that 19 answer is different than your question. 20 MR. PARIS: Yeah. 21 MR. BONEZZI: Your question was infection 22 as a general statement as opposed to a toxin-released 23 mediated sepsis. 24 A. I wasn't trying to be evasive. 25 Q. (By Mr. Paris) I was trying to be very CONTINENTAL COURT REPORTERS, INC. 50 1 specific in my question. 2 A. And I was trying to be specific in my answer. 3 Q. Okay. So retrospectively, when do you think 4 that the infection first manifested itself in this 5 patient? 6 A. I would say the patient -- with the 7 retrospective scope? 8 Q. Sure. 9 A. I could say that when the patient was having 10 shakes she might have had an infection. But I can 11 definitively say when they saw her and her vital signs 12 were radically changing, they started the antibiotics, 13 clearly at that point the toxin was released. 14 Q. Okay. You do know when they started the 15 antibiotics, don't you? 16 A. The following day. Yes. 17 Q. At 11:30 a.m. 18 A. Yes. 19 Q. Okay. But going back, would you -- would it 20 be your opinion that the infection in this patient first 21 started to manifest itself when she had a left shift? 22 When she had a fever? 23 A. Let me try to answer that question and not be 24 invasive when I answer that. 25 Retrospectively, we always try to put CONTINENTAL COURT REPORTERS, INC. 51 1 things in a sequential factor. Reading the case 2 prospectively, since I read the case from the beginning 3 to the end, as a clinician, I would say I have a patient 4 with a vaginal delivery, possible PIH, she developed a 5 fever to 101. 6 Q. I don't mean to cut you off. But the first 7 time I asked this question it was retrospectively. When 8 did the infection first manifest itself? 9 A. Well, if you want me -- all right. The 10 definitive retrospective answer would be certainly when 11 they started the antibiotics. 12 MR. BONEZZI: I want to make sure that 13 we're not equating "infection" to "toxin release." 14 MR. PARIS: I can't ask -- 15 MR. BONEZZI: No. No. I understand. 16 The only way I can -- I can ask is somebody provide a 17 definition of "infection" because I think the answers 18 are different than the question being asked. 19 MR. PARIS: I spent some time -- 20 A. The pathologist provided us with an answer. 21 Q. (By Mr. Paris) I spent some time at the 22 outset of this case trying to get an understanding of 23 criteria for postpartum infection and why we spend 24 some time, and you educated me in that regard. I'm 25 using the term "infection" in the same way that we've CONTINENTAL COURT REPORTERS, INC. 52 1 defined it at the outset. 2 But what is your answer? 3 A. Then I'll give that answer. 4 Q. Let me ask a clean question. Let me get a 5 clean answer. 6 Retrospectively, when in your opinion did 7 this postpartum infection first manifest itself? 8 MR. SCHOBERT: Objection. 9 Go ahead. 10 A. Retrospectively, when she started to have 11 shakes, she could have had an infection. There are many 12 signs of infection and only answer the qualifier. And I 13 could even say when she had the fever she could have a 14 sign of infection. Yet, I will qualify that by saying 15 many patients I see after a vaginal delivery will have 16 febrile morbidity from the old blood tissue that's 17 coming out of the uterus, and mastitis, other things, 18 and not be infected, not require antibiotics, and not 19 progress. 20 So prospectively, I would say the 21 standard of care was met. Retrospectively, if you're 22 asking me when the infection was started, there are many 23 points on the curve you could point to, and I would 24 agree with all of them. 25 Q. (By Mr. Paris) And let's deal with my CONTINENTAL COURT REPORTERS, INC. 53 1 question, which is, retrospectively, did the 2 infection first manifest itself when she had an 3 increased elevated white count and bands in excess of 4 10 percent? 5 A. I would say retrospectively, yes. 6 Q. Okay. And in addition to that abnormal lab 7 value that I just described, when she had a fever of 101 8 or greater, in conjunction with that abnormal lab, would 9 that be evidence of the infection manifesting itself? 10 A. I will answer the way you answered the 11 question. Yes, it could. 12 Q. And when the patient -- did the patient 13 retrospectively have evidence of an infection at 14 11:30 p.m., based upon the lab values that came back 15 within 45 minutes of that time, that being the drop in 16 the white count and the dramatic left shift of 52 bands? 17 A. She could have. 18 Q. How would you retrospectively characterize the 19 severity of her infection at 11:30 p.m.? 20 A. Just so I understand your question, are you 21 asking me to give a prospective opinion based on just 22 the clinical data up until 11:30 p.m. about the severity 23 of her infection? 24 Q. Retrospectively, based on everything that you 25 know at this time, I want you to characterize the CONTINENTAL COURT REPORTERS, INC. 54 1 severity of her infection based on the 11:30 p.m. lab 2 values. 3 MR. BONEZZI: Objection. 4 Go ahead and answer. 5 Q. (By Mr. Paris) And the other information 6 that was available before 11:30 p.m. 7 MR. BONEZZI: Objection. 8 MR. JEFFERS: Objection. 9 A. But not after? 10 Q. (By Mr. Paris) But not after. 11 A. Okay. Well, then I think she had febrile 12 morbidity, which flows into a common pathway of many 13 problems, the first of which was concern about her liver 14 with PIH -- liver necrosis can be a serious problem 15 post-PIH; concern about mastitis, which can be 16 associated with infections; febrile morbidity, not 17 infections, where a patient has a temperature and on 18 occasion due to mild symptoms, bladder infections, 19 episiotomy irritation. But at that point, based on what 20 I had read, I would not suspect this patient had a 21 life-threatening infection. 22 Q. How about just an infection? 23 A. Possibly she could have had an infection or 24 febrile morbidity. She falls into the lowest risk 25 group. She had a vaginal delivery, her other vital CONTINENTAL COURT REPORTERS, INC. 55 1 signs weren't off the wall, and she looked pretty good. 2 Often we will wait for cultures and start antibiotics. 3 Defining the infection, particularly like we have with 4 people with bladder infections, to use an example, we'll 5 wait for the culture and then start the antibiotics. 6 Vaginal deliveries, many a time on round I'd wait even 7 with other people. And making rounds, you do the 8 culture. It comes back. It's a vaginal delivery. It's 9 so rare. And then all of a sudden a day or two later 10 gonorrhea comes back. 11 Q. You made the statement that the patient looked 12 well. 13 A. Well -- 14 Q. What was the basis for -- 15 A. -- she didn't look like she was in septic 16 shock. She wasn't hypertensive, she was able to talk to 17 the doctor, she had no signs of extremeness I have the. 18 Q. Is there anything less than extremeness that 19 might cause a reasonably prudent physician to suspect 20 infection at that time? 21 A. Again, I would answer the question the way I 22 answered it before, because you're asking about this 23 case specifically. 24 Q. Of course. 25 A. Which is if the patient, say, had a C section CONTINENTAL COURT REPORTERS, INC. 56 1 with prolonged rupture of membranes, a lot of blood 2 lost, hematoma, fever, and tachycardia during labor, 3 that would have triggered me to lean more toward 4 infection. But there again, if I have a patient who had 5 a vaginal delivery, the incidence of infection is so 6 rare, we actually overuse antibiotics in many ways. So 7 I'd say she had febrile morbidity then. Whether or not 8 that was an infection at that time -- and I'm not trying 9 to put on my retrospective/prospective blinders -- 10 that's what I would call it at that time. 11 Q. Do you agree Group A strep is very sensitive 12 to penicillin? 13 A. Yes, I would. 14 Q. Penicillin kills the bacteria almost 15 immediately; does it not? 16 A. Yes, it does. 17 Q. And it stops the release of toxins, correct? 18 A. If the bacteria -- well, if the bacteria is 19 killed before it releases the toxin and if the 20 antibiotic gets to the target tissue site where the 21 infection is. 22 Q. Then it will stop the release of toxins? 23 A. If it reaches the organism, yes, it does. 24 Q. Sure. 25 A. In concentrations of blood levels and MIC's CONTINENTAL COURT REPORTERS, INC. 57 1 that are described in the literature. 2 Q. Then the effect of no penicillin is that the 3 bacteria keeps growing and releasing toxins, correct? 4 A. Well, I would say that penicillin in low doses 5 actually can develop resistance and higher problems 6 sometimes. But, yes, if you don't give the antibiotics, 7 it doesn't kill the organism. 8 Q. And at what rate -- if you know, if you have 9 an opinion, at what rate does the GAS bacteria grow? 10 A. Again, that would depend on inoculum and 11 environment. The inoculum would be the amount of 12 bacteria colony-forming units that are deposited there, 13 and the environment would be the nutrients that are 14 there. I would say that in the uterine lining, in a 15 devascularized area where antibiotics do not penetrate 16 that well in an infected target tissue site, I would say 17 the bacteria could grow rapidly. By "rapidly," do I 18 mean colony counts of 10 to the 1, colony counts per 19 milliliter or 10 to the 2? You can come back in 12 20 hours and they will be up to 10 to the fourth or fifth 21 or 24 hours. Yes, it can divide rapidly and grow 22 rapidly. Yes. 23 Q. How about in the bloodstream? 24 A. The blood treatment is a different site, 25 because the bloodstream is different in that antibodies, CONTINENTAL COURT REPORTERS, INC. 58 1 all those great things in our bodies are in the 2 bloodstream. That is one of the problems internal 3 medicine doctors and ID have a problem with GYN 4 infections, in that they're used to looking at blood 5 levels at target tissue sites that are not 6 devascularized. You're asking me about a uterine 7 infection that's being devascularized that's the target 8 tissue. And that's the problem with -- with studying 9 infections in this area. So if I were able to do a 10 hysterectomy of a serum blood level and a uterine blood 11 level, I could tell you whether they were getting there. 12 Q. Do I understand that dead Group A strep 13 bacteria do not release toxins? Is that a correct 14 statement? 15 A. I would not disagree with that statement. 16 Q. Okay. I would like to try to explore a little 17 bit more. Once the bacteria, in your opinion, has 18 colonized in the uterus -- 19 A. Yes. 20 Q. -- it somehow gets into the bloodstream, 21 doesn't it? 22 A. Not necessarily at all. 23 Q. In this case did it? 24 A. I'm not sure. Certainly, the toxin did. But 25 whether or not the organism -- and just like with Toxic CONTINENTAL COURT REPORTERS, INC. 59 1 Shock Syndrome -- to use this analogy that you brought 2 up earlier -- Toxic Shock Syndrome is not associated 3 with the organism in the bloodstream. It's associated 4 with the toxin in the bloodstream, just like this case. 5 She probably wasn't bacteremic. She had toxin in her 6 bloodstream. 7 Q. And at what point did the toxin enter the 8 bloodstream? 9 A. God knows. I can't answer that. I certainly 10 know it was there when she was in extremeness. 11 Q. Are there different phases of shock, or once 12 you go into shock, that's it? 13 A. Well, it depends what the shock's due to and 14 what organism -- 15 Q. GAS. GAS. 16 A. Once GAS toxin's been released, it's a 17 progression. Again, there aren't well-controlled 18 studies because the progression proceeds to an untoward 19 event. 20 Q. And can you tell me what the potency of the 21 toxins are after they're produced? In other words, how 22 long do they continue to produce harmful effects in the 23 body after they are produced? 24 A. Again, this is a post-defense question you're 25 asking me that I can't answer based on any reasonable CONTINENTAL COURT REPORTERS, INC. 60 1 data. There may be rodent data where they inject the 2 toxins over a period of time. But I'm unaware of any 3 human data where we've had inoculum size, inoculum of 4 toxin. There are speculations. And, obviously, it can 5 be lethal. What amount? It could be very small if the 6 cascade of shock is triggered. 7 Q. It is the -- do I understand that it is the 8 toxins attacking the end organs that result in the 9 shock? 10 A. It's a systemic attack. 11 Q. And the toxins are -- are they released in 12 proportion to the amount of GAS organisms? 13 A. Again, that's a -- that's an interesting 14 question, both legally and scientifically. Because you 15 could have one colony that produces the toxin and you're 16 dead, and the majority of them aren't. 17 Again, that's a theoretical question. 18 It's like, do you want to be written by the little -- 19 bitten by the little rattlesnake or the big one? I 20 don't know. But which one has the most potent toxin, 21 you know, is the problem. Coral snakes have a more 22 potent toxin, smaller amount. We're talking about 23 toxins. 24 Q. Are you aware that Beth had a second blood 25 culture that was run after her antibiotics were CONTINENTAL COURT REPORTERS, INC. 61 1 administered? 2 A. I'd have to look at the chart specifically, 3 but I'm sure she did. 4 Q. It's my understanding that that second culture 5 showed no growth of strep A in her blood. 6 A. Which is, again, if you understand this 7 disease and if you dealt with patients like this, like 8 you brought up with Toxic Shock Syndrome, you don't 9 culture the organism from the bloodstream. The toxin's 10 released, and that's the way the disease works. 11 So that doesn't surprise me at all. 12 Q. Where did they culture the organism? 13 A. As I recall, it was in her endometrium on 14 autopsy. 15 Q. Okay. 16 A. And I don't know if they had another culture 17 from her. I'd have to look. 18 Q. Well, the -- 19 A. The fact that you don't have a positive blood 20 culture, the toxin releasing is the nature of the 21 disease. 22 Q. Well, what if she did have a positive blood 23 culture the first time? 24 A. Wouldn't matter. Group A strep, if she's 25 bacteremic -- you could be bacteremic from Group A strep CONTINENTAL COURT REPORTERS, INC. 62 1 and not have a toxin-releasing organism, and she'd be 2 alive. I'm not trying to be evasive. 3 Q. I think we can pretty much agree that there's 4 not one seminal study on the survival rates for 5 postpartum patients with Group A strep. Is that right? 6 A. Group A strep colonization or Group A strep 7 toxin-producing? 8 Q. Let me rephrase the question. Let me rephrase 9 the question. There's not one seminal study on survival 10 rates of postpartum patients with Streptococcal Toxic 11 Shock Syndrome? 12 A. I would agree with that. 13 Q. You read Dr. Martens' depositions. Did you 14 disagree with his statement that he had treated seven 15 patients with postpartum GAS and none of them died? 16 A. Well, I would say -- I mean, the only way I 17 can interpret that is, A, I'd have to review the cases 18 and see if, A, they had Group A strep with a toxin 19 producer. Because Group A strep colonization from a 20 boil on your butt is not what you're talking about when 21 the toxins are produced. B, if he was talking about 22 Group A strep toxin-producing patients and he saw seven 23 patients, he was here with me for about -- and 24 Dr. Farrow for about three years, the largest medical 25 center in world. We might have had one then. Then he CONTINENTAL COURT REPORTERS, INC. 63 1 went to very small institutions. And you're telling me 2 he saw probably 30 percent of the Group A strep 3 toxin-producing postpartum deaths in the country 4 himself? 5 Q. I'm not. 6 A. No. I'm just saying that's how I interpret 7 his comment. He exceeds what I believe is reported in 8 the -- in the world. You know, something -- so I don't 9 know how to interpret that statement because it goes 10 beyond what I understand the incidence of the disease 11 is. But maybe he was speaking in a vagary that I don't 12 understand. 13 Q. No. It looked very -- it didn't seem vague to 14 me. 15 But did you ever read any of Dr. -- the 16 account that Dr. Martens published involving a young, 17 otherwise healthy, girl that developed GAS postpartum; 18 and by the time she presented to the hospital, she was 19 in shock with metabolic acidosis? 20 A. I don't recall reading that. I would be 21 curious if, A, they isolated the toxin in that case. 22 Q. Okay. And if she was cured and discharged 23 after six days in the hospital, it would be your 24 contention that this was not a GAS postpartum infection 25 which released exotoxins? CONTINENTAL COURT REPORTERS, INC. 64 1 A. I would say that's one possibility. The other 2 possibility is that this is an extremely atypical 3 variant of this organism, and it may have been a less 4 virulent toxin. This is not the standard for this 5 disease. 6 Q. Was -- in this case, was the toxin typed? 7 A. Not that I'm aware of, but I'd have to look at 8 the record. I didn't see that. 9 Q. Was a toxin identified? 10 A. Not that I'm aware of. 11 Q. Well, then why do you say that it was the 12 toxins that killed her? 13 A. She's dead and she had all the phenomenon of 14 the toxin releasing, phenomenon. And, as you said, she 15 didn't have a positive blood culture, so the toxins 16 killed her. Out of your own mouth gave me the answer. 17 Q. Okay. And if she did have a positive blood 18 culture? 19 A. Again, to reiterate, Toxic Shock Syndrome, if 20 one were to read and look at those toxin-producing 21 syndromes, they're classically associated with not 22 isolation of the organism from the blood, but out of 23 site, and the toxin goes through the bloodstream. That 24 is how the disease is identified, how it's described, in 25 my experience. CONTINENTAL COURT REPORTERS, INC. 65 1 Q. If nobody has identified the toxin in this 2 case, how can you say it was the toxins that killed her? 3 A. Because she had all the clinical manifest -- 4 just like with Toxic Shock Syndrome. The majority of 5 the cases who died from that disease did not have the 6 organism isolated or the toxin isolated. What happened 7 was they had negative cultures, and they had all the 8 clinical manifestations of the disease, and then they 9 had the particular organism that's associated with the 10 toxin release isolated. 11 Q. Doctor, can you -- 12 A. And the other thing that's a problem is what 13 triggers the toxin release is very unique. We do not 14 know what triggers all the toxin releases. So I'd have 15 to get a -- a necrotic uterus, try to do some experiment 16 undefined to try to figure out how to trigger toxin 17 release in Group A strep. And that's one of the 18 problems. We do not understand why the toxin's 19 released. 20 Why do I think she had a toxin release? 21 Because she had all the phenomenon of a toxin-releasing 22 death, which is clearly outlined both in the chart and 23 described very well in all the records. 24 Q. Doctor, can you have a GAS postpartum 25 infection that goes untreated and develops into septic CONTINENTAL COURT REPORTERS, INC. 66 1 shock and death in the patient? 2 A. Can you have one that's untreated and dies? 3 Q. Yeah, without the release of toxins. 4 A. I would say that is extremely uncommon. If 5 one were to have an -- I'd say that's extremely 6 uncommon. 7 Q. And why is that uncommon? 8 A. Because Group A strep without the toxin 9 release is not as virulent an organism. It's like 10 saying, "Can you shoot me" when you don't have a gun. 11 Q. So GAS infections cannot -- without toxins, 12 cannot produce shock? 13 A. GAS without the toxin production, can be -- 14 can you have associated infections, and there probably 15 are case reports of mixed infections where Group A strep 16 has been isolated and the patient progressed with, say, 17 necrosis of a joint or a hip or a vital tissue. A 18 localized abscess that eroded through and patients died 19 and the toxin wasn't released, yes, I think that could 20 occur. Is Group A strep without the toxin-producing as 21 virulent an organism? Absolutely not. 22 Q. And even if it's untreated? 23 A. There's a def -- there's a distinction between 24 colonization, because in soft tissue infections, in the 25 vagina, there are many organisms. And how you pick one, CONTINENTAL COURT REPORTERS, INC. 67 1 which is the offending organism, in a mixed soft tissue 2 infection is one of the problems with our literature. 3 Q. Did you read the study by Anteby and Israel in 4 1999 dealing with postpartum GAS patients? 5 A. No. 6 Q. And if 46 of those 47 patients recovered 7 within four days with antibiotics, it's because there 8 were no toxins released? 9 A. If they're -- if they're alive. 10 Q. Okay. And if three of those patients who went 11 into septic shock took longer to heal, that was very 12 uncommon? 13 A. Again, again, I'd say I'd have to specif -- 14 there are many variables with these kind of studies. 15 And one of the problems with literature is they are 16 mixed infections. Many times the postpartum infection 17 with the type of wound infection that you alluded to are 18 associated with E. coli and mixed anaerobic infections. 19 The fact that they isolated Group A strep alone or with 20 many other organisms doesn't necessarily mean that was 21 the offending organism. 22 Are there other postpartum infections 23 where patients go into shock and die due to other 24 organisms? Absolutely. And do they respond better to 25 antibiotics? Yes. CONTINENTAL COURT REPORTERS, INC. 68 1 Q. So in this case, because you've opined that 2 she had GAS and the release of toxins -- 3 A. Yes. 4 Q. -- survivability did not depend on factors 5 such as the time of diagnosis? 6 A. Yes. 7 Q. Correct? 8 A. Correct. 9 Q. It didn't depend on such factors as how early 10 antibiotic therapy is started? 11 A. In my opinion, antibiotic therapy would 12 not have -- no, it didn't, unless I had a crystal ball 13 that said, "Let's give her antibiotics before she has a 14 fever, before she's pregnant," like we do with Toxic 15 Shock Syndrome patients where we know they're colonized. 16 Q. Also in this case, survivability did not 17 depend on a factor such as the underlying health of the 18 patient? 19 A. I'm not aware that she had any 20 immunocompromised factors. She was a healthy patient. 21 Q. Well, I'm saying her survivability didn't -- 22 that was not impacted. Survivability was not impacted 23 by virtue of her good health? 24 A. That's right. 25 Q. And, apparently, her survivability was not CONTINENTAL COURT REPORTERS, INC. 69 1 impacted by the factor that she was in a hospital at the 2 time of the onset of her symptoms? 3 A. No, it wasn't. Yeah. That's correct. 4 Q. Nor was her survivability impacted on the 5 factor that she was in an urban setting with ready 6 access to infectious disease experts and other experts? 7 A. That's true. 8 Q. Or the fact that she was within 20 minutes 9 from a tertiary hospital? 10 A. That's true. 11 Q. Were there any epidemiological factors that 12 would favor survival in this woman? 13 MR. BONEZZI: Objection. 14 Go ahead and answer. 15 A. Again, this is a rare disease with a rare 16 organism triggering this. We still don't know what 17 triggers this in rare settings. I view this as an act 18 of God almost. 19 Q. (By Mr. Paris) Her chance of survival was 20 just as good had she given birth at home as opposed 21 to in the hospital? 22 A. No. That's not true. Her survive -- the baby 23 probably would have done poorly. She might have died of 24 preeclamp -- of eclamptic seizures before she developed 25 this other phenomenon. So I think the fact that you CONTINENTAL COURT REPORTERS, INC. 70 1 have a living baby is a credit to the doctors who are 2 very conscientious. 3 Q. At what point in time, in your opinion, did 4 Beth have less than a 100 percent chance of death? 5 MR. BONEZZI: Objection to the form. 6 MR. SCHOBERT: Objection. 7 MR. PARIS: Let me rephrase it. 8 MR. SCHOBERT: Yes, please. 9 Q. (By Mr. Paris) I think you've rendered an 10 opinion that Beth had virtually no chance of 11 survival. Is that correct? 12 A. That's true once the toxin was released. 13 Correct. 14 Q. At what point in time, in your opinion, did 15 Beth have a chance of survival? 16 MR. JEFFERS: Objection. He just 17 answered that. He just told you that. He told you that 18 three or four times already during the deposition. By 19 definition, he just answered your question during 20 your -- during the time you just put it again. 21 Q. (By Mr. Paris) Go ahead, Doctor. 22 A. Again, I'll say when the toxin -- before the 23 toxin was released. When that was, I don't know. To be 24 not callous, but clear, even in the 21st century -- 2001 25 or whatever year this occurred, 1999, I believe -- CONTINENTAL COURT REPORTERS, INC. 71 1 giving birth on occasion is associated with death. If 2 she hadn't got pregnant -- she's a postpartum death, a 3 non-preventible postpartum death. 4 Q. Doctor, the toxins could have been released 5 after 7:30 p.m. Friday night, correct? 6 MR. SCHOBERT: What date is Friday night 7 just so we're clear? 8 MR. PARIS: June 25th. 9 MR. SCHOBERT: Okay. 10 A. Could have been. 11 Q. (By Mr. Paris) They could have been 12 released after 8:30 p.m. Friday night? 13 A. Could have been. 14 Q. And you have no way of knowing one way or the 15 other whether or not there's a probability that the 16 toxins were released prior to 8:30 p.m. Friday night -- 17 MR. BONEZZI: Objection. 18 Q. (By Mr. Paris) -- correct? 19 MR. BONEZZI: Objection. 20 A. I do not and no one in the world does. 21 Q. (By Mr. Paris) If Beth had not died -- 22 A. Yes. 23 Q. -- from this disease, in your opinion, would 24 she have had a normal life expectancy? 25 MR. JEFFERS: Objection. CONTINENTAL COURT REPORTERS, INC. 72 1 MR. BONEZZI: Objection. 2 A. I -- if she wasn't dead, she'd be alive, and I 3 assume living a normal life. 4 Q. (By Mr. Paris) No. Would she have had any 5 effects from this disease process? 6 A. I mean, If she didn't have the fever and 7 didn't -- 8 Q. No. No. 9 Had she survived this event, would she 10 have been left with any sequelae that would have 11 impacted her life expectancy? 12 MR. JEFFERS: Objection. 13 MR. BONEZZI: Objection. 14 A. I can't give expert opinion on her neurologic 15 status when she, you know, was at the other hospital. 16 And the neurologic sequelae of shock can be associated 17 with adult respiratory, with neurologic symptoms; it can 18 be associated with Adult Respiratory Distress Syndrome, 19 all of which are severely disabling. So whether or not 20 she would have been neurologically intact, I do not 21 know. 22 MR. PARIS: Okay. Let's -- let's take a 23 short break, okay? 24 VIDEOGRAPHER: Off the record at 3:43. 25 (Recess from 3:43 p.m. to 3:49 p.m.) CONTINENTAL COURT REPORTERS, INC. 73 1 VIDEOGRAPHER: On the record at 3:49 2 p.m., beginning Tape 2. 3 Q. (By Mr. Paris) Doctor, just so I'm clear 4 before I move on to another subject. Before the 5 toxins are released with Group A strep, antibiotics 6 would kill the bacteria and prevent the release of 7 toxins? 8 MR. BONEZZI: Objection. 9 MR. JEFFERS: Objection. 10 MR. BONEZZI: That's not what he said. 11 MR. PARIS: Okay. 12 MR. BONEZZI: It depends on the location. 13 MR. PARIS: Let me -- let me go back. 14 MR. JEFFERS: He's already addressed 15 that. Objection. 16 MR. BONEZZI: Yeah, he has, David. 17 MR. GORDON: It doesn't matter. 18 MR. BONEZZI: What do you mean it doesn't 19 matter? 20 MR. GORDON: It doesn't matter. I 21 mean -- 22 MR. BONEZZI: You get to -- you get a 23 shot at asking the same question four or five times? 24 MR. GORDON: No. No. No. 25 MR. BONEZZI: It does matter, Harlan. CONTINENTAL COURT REPORTERS, INC. 74 1 Go ahead. 2 MR. GORDON: No. 3 MR. BONEZZI: Yeah, it does. 4 A. Could you repeat the question just one more 5 time? 6 Q. (By Mr. Paris) Before the toxins are 7 released, will antibiotics kill the bacteria and 8 prevent the release of toxins? 9 MR. BONEZZI: Objection. 10 MR. JEFFERS: Object. 11 A. The antibiotics will kill the bacteria. And 12 if the bacteria doesn't grow, isn't in existence, 13 there's no toxin. Whether or not that particular strain 14 is a toxin-producing strain is the issue. And why some 15 strains release toxins and others don't is the unknown. 16 So I can't -- you know... 17 Q. (By Mr. Paris) Is the goal then, Doctor, 18 to deliver antibiotics to kill the bacteria so that 19 toxins are not released? 20 A. The goal -- the only thing antibiotics can do 21 is kill bacteria. If there's a toxin-producing bacteria 22 and the toxin's released when the -- the antibiotics 23 have nothing to do with the toxin. 24 Q. Understood. But the penicillin will kill the 25 GAS bacteria? CONTINENTAL COURT REPORTERS, INC. 75 1 A. Yes. 2 Q. Okay. And the goal is to deliver the 3 penicillin to kill the GAS bacteria before the toxins 4 are released? 5 A. That would be a goal. 6 Q. Okay. And does the number of toxins, for lack 7 of a better word on my part -- but is it the number of 8 toxins that are important that impact the survivability? 9 A. It's a host virulence factor that's an 10 unknown; it's a black box. You could have one toxin, 11 one molecule that could trigger the mechanism or it 12 could be a larger molecule, a larger group of toxins, 13 and that's an unknown. 14 Q. Okay. So there is a scenario in which one 15 toxin that is released by one organism can cause a 16 cascade of infections, bacteremia, sepsis, and septic 17 shock? 18 MR. BONEZZI: Objection to the form of 19 that question. 20 Go ahead. 21 MR. JEFFERS: Objection. 22 A. This is an unknown. That's the nature of 23 toxin-releasing organisms. Whether it's a small amount 24 or a large amount, we don't know. 25 Q. (By Mr. Paris) Do you have an opinion one CONTINENTAL COURT REPORTERS, INC. 76 1 way or the other whether it's more likely to be one 2 toxin or a great number of toxins -- 3 MR. BONEZZI: Object. 4 Q. (By Mr. Paris) -- or is that strictly 5 speculation? 6 A. Speculation. 7 Q. That's fine. 8 Have you come to be aware of the 9 interaction between Dr. Hahn and the nursing staff at 10 Parma Hospital at 12:45 a.m. on Saturday, June 25th? 11 A. I'd have to look. 12 MR. PARIS: Is that June 26th? 13 MR. SCHOBERT: June 26th. Yes. 14 A. I'd have to look at the -- I'd like to look at 15 the record specifically, if you want. 16 Q. (By Mr. Paris) Okay. I mean, and I'll try 17 to -- I will tell you that there is a dispute between 18 the testimony of Nurse Prokop and Dr. Hahn as to what 19 specific details were transmitted over the phone 20 about the lab values, the 11:30 p.m. lab values. 21 Have you reviewed that part of the chart? 22 A. I'm looking at this to make sure we're talking 23 about the same -- so we're looking at 6-26. I see, 24 "Dr. Hahn called and informed of lab results, and 25 patient states restless, anxiety. Output, Dr. Shah CONTINENTAL COURT REPORTERS, INC. 77 1 examines, etcetera," whatever that is. 2 Q. Okay. Now, you're aware of what the lab 3 values are that we're talking about? Those labs were 4 drawn at 11:46 p.m. 5 A. We're talk -- you're talking specifically 6 about which lab values? The CBC? 7 Q. Yeah. 8 A. I'm aware of that. You want me to look at 9 that? 10 Q. Do you know what the labs -- how they came 11 back? 12 A. Oh, just so I don't misquote, let me look 13 specifically. I want to make sure I'm on the same page 14 of the same book. 15 Q. 2330 labs. 16 A. You're talking about the white count of 4,600? 17 Q. Right. There had been a precipitous drop from 18 16.1 down to 4.6? 19 A. Yes. 20 Q. And you're aware of a left shift that exits in 21 the bands? 22 A. Yes. 23 Q. She went from 13 bands up to 52 bands? 24 A. Yes. 25 Q. And there were six metamyelocytes? CONTINENTAL COURT REPORTERS, INC. 78 1 A. Yes. 2 Q. Okay. Now, are you aware that Dr. Hahn claims 3 that the nurse failed to tell him specifically about 4 those lab results? 5 A. I wasn't aware that there was a dispute there. 6 Q. Okay. In your opinion, would the accepted 7 standard of care be for Dr. Hahn to specifically request 8 of the nurse during that conversation what the specific 9 lab values were? 10 MR. BONEZZI: In other words, asking 11 specifically what's the white count? What's this? 12 What's that? 13 MR. PARIS: Correct. 14 A. It depends. I think the general variable 15 would be the white count, the hematocrit, and the 16 platelets would be one that I'd be concerned about. The 17 differential is a shift, but I don't feel that this 18 information would have changed anything. 19 Q. (By Mr. Paris) Well, let's just talk about 20 standard practice. In a patient who had a 101.6 21 temperature, who had some abnormal white blood counts 22 previously, would it -- would it be within the 23 accepted standard of care for Dr. Hahn to ask what 24 those specific labs were -- 25 A. In this -- CONTINENTAL COURT REPORTERS, INC. 79 1 Q. -- in this circumstance? 2 A. If you're talking about standard of care? 3 Q. Yes. 4 A. Not highest standard, but standard of care? 5 Q. What a reasonably prudent -- 6 A. Standard of care at 11:30 at night, called 7 with a patient like this, I'm happy I got a white count 8 and I got a CBC. The differential is not the 9 deal-breaker for me. If her white count was over 10 20,000, I'd say, "Gee things are starting to cross the 11 barrier." And she's not neutropenic, I'm happy with 12 those extreme variables. 13 And the standard of care, in my opinion, 14 isn't always to get the differential given to you. I'm 15 actually very impressed that they got a white count, 16 they got a crit, they got the tests run right away. 17 They're, if anything, probably -- and the patient was 18 seen -- above the standard of care of most hospitals 19 that I've even worked in. 20 Q. Would -- 21 A. And the fact that they got it back in such a 22 timely fashion. 23 Q. Okay. If the -- if the nurse told Dr. Hahn 24 specifically what the white blood count was and the 25 differential, should infection have been in his CONTINENTAL COURT REPORTERS, INC. 80 1 differential diagnosis at that time? 2 A. As you would say, and I would say in this 3 state, could have. 4 Q. Would it have -- would the standard of care 5 required him at that time to administer antibiotics 6 empirically and -- 7 A. Not necessarily. 8 Q. -- blood cultures? 9 A. Not necessarily at all. 10 Q. Well, under what circumstances would it? 11 A. Well, if when he saw the patient she showed 12 other vital sign changes, she looks septic. And again, 13 as we had discussed earlier in the deposition, there 14 were other risk factors put into play. It's not just 15 one isolated temperature or white count or banding. 16 Q. Let me -- let me give you another factor to 17 take into consideration. If the nurse called the doctor 18 at that 12 -- at 12:45 and said, "Doctor, we are 19 concerned about this patient. She doesn't look well to 20 us. She's restless. She has anxiety. She has a 21 decreased urine output. Her" -- 22 A. And you told me that? You know what I'd say 23 to you in this patient? I'm worried about having 24 postpartum PIH. And the chance of postpartum PIH and 25 eclampsia decreased -- you described progression of PIH, CONTINENTAL COURT REPORTERS, INC. 81 1 not an infection, particularly in this setting. 2 Q. What would you do? 3 A. I'd do -- I'd go see -- the patient was seen. 4 Q. What would you do? 5 A. I would go see the patient and make a clinical 6 decision based on many factors. 7 As you know, especially today, nurses -- 8 the fact that the nurse is calling you -- normally in my 9 practice, I get called, when I walk out of this room on 10 a weekend, every 15 minutes for the entire weekend for 11 the practice volume I have. Nurses call because they, 12 A, legitimately have concerns; and, B, they've been 13 trained to call. How one sorts out what's real and not 14 is very simple. You ask for the vital signs. 15 Q. And you'd go see the patient yourself? 16 A. Well, I would see -- it depends on what the 17 nurse told me. I usually -- many nurses change -- and I 18 don't know in this case. It was 11:00 o'clock, right? 19 What happens at 11:00 o'clock? Change of shift. It's 20 the change-of-shift call. 21 Q. I'm -- 22 A. But I'm just saying -- I'm just saying nurses 23 usually work 7:00 to 11:00. It is not uncommon to be 24 called after 11:00 o'clock because the shift has 25 changed. So if you're asking me about standard of care CONTINENTAL COURT REPORTERS, INC. 82 1 and getting calls from nurses, you get lots of calls 2 from nurses, and it's very hard sometimes to sort out 3 what's real and what's not. 4 Q. Based on what I've asked you to assume was 5 part of that conversation, would you go see the patient? 6 A. Well, I try not to assume. But -- and I 7 didn't hear the conversation. I just saw that two 8 lines: "Patient is" -- 9 Q. I've asked you to assume -- 10 A. I would -- I, as my -- my -- I probably would 11 have seen the patient, thinking she had progressive PIH. 12 Q. And you believe that that's what a reasonably 13 prudent physician would do under the same or similar 14 circumstances? 15 MR. BONEZZI: Objection. That's not what 16 he said. 17 Q. (By Mr. Paris) Well, that's what you would 18 do. Do you believe that that's what a reasonably 19 prudent physician would do under the same or similar 20 circumstances? 21 A. Again, it depends, you know, did he know the 22 nurse? Did he know the patient? What sort of variables 23 are in there? And I wasn't there. Retrospectively, you 24 see patients. Prospectively -- this is many calls -- 25 the patient's a little restless, anxious. Patients get CONTINENTAL COURT REPORTERS, INC. 83 1 restless and anxious. They want sleeping medicines. 2 There are a lot of things that occur with patients 3 postpartum. And, as I say, you get calls every 15 4 minutes some weekends. And how do you sort them out? 5 And this is a change of shift call, too, 11:00 o'clock. 6 The patient is restless. What does she want? Does she 7 want a sleeping pill? I mean, I don't know. 8 Q. So would you disagree with Dr. Hahn if he said 9 that the nurse, in failing to tell him the differentials 10 at that time, breached the accepted standard of nursing 11 care? 12 MR. BONEZZI: Objection. That's not what 13 he said. 14 A. No. I would say that the differential 15 wouldn't have changed or may not have changed my 16 approach to this case at all. 17 Q. (By Mr. Paris) Whether the communication, 18 the failure to communicate the accurate labs was a 19 breach of the accepted nursing standard, do you 20 believe -- 21 A. No. 22 Q. -- that to be the case? 23 A. No. 24 Q. You don't believe that's a breach? 25 A. No. No. CONTINENTAL COURT REPORTERS, INC. 84 1 Q. Okay. And if Dr. Hahn testified that Nurse 2 Prokop deviated from the accepted standard of nursing 3 care by failing to advise him during a 3:45 a.m. 4 telephone conversation of abnormal blood pressure 5 readings -- 6 A. That's his opinion. 7 Q. -- would that be -- 8 MR. BONEZZI: Objection. 9 Q. (By Mr. Paris) -- would you agree with him 10 that that's a breach of the standard of care? 11 A. Well, I'd have to know how abnormal they were. 12 And that's his opinion. I don't know -- you know... 13 Q. You don't necessarily agree or disagree with 14 that, correct? 15 A. Right. 16 Q. Okay. Well, the reason I'm exploring is 17 because you've said that the standard of care has been 18 met by apparently everyone who delivered care to this 19 woman. Is that right? 20 A. Yes. 21 MR. SCHOBERT: Objection; asked and 22 answered. 23 Q. (By Mr. Paris) Okay. 24 A. But if I understood your question, you were 25 asking me an opinion of someone else's opinion about CONTINENTAL COURT REPORTERS, INC. 85 1 nursing care. 2 Q. Yeah. I want to know if you agreed with 3 Dr. Hahn. 4 A. And I said I -- you know, "yes" or "no"? I 5 don't know. 6 Q. You can't agree or disagree? 7 A. He personally talked to the nurse. He has 8 more information in his database than I do. 9 Q. If Dr. Hahn believed that there was a 10 nine-hour delay in the recognition of this infection 11 because of the miscommunications by the nursing staff to 12 him, in your opinion, did he have an obligation to point 13 that out in the discharge summary? 14 MR. BONEZZI: Objection. 15 MR. JEFFERS: Objection. 16 MR. SCHOBERT: Objection. 17 A. Say that question again. That's a complicated 18 question. 19 MR. PARIS: Can you read that back 20 please? 21 (The last question was read) 22 MR. GORDON: Hang on a second. 23 MR. PARIS: Off the record. 24 VIDEOGRAPHER: Off the record at 25 4:05 p.m. CONTINENTAL COURT REPORTERS, INC. 86 1 (Recess from 4:05 p.m. to 4:06 p.m.) 2 VIDEOGRAPHER: On the record at 4:06 p.m. 3 MR. PARIS: Can you read the question 4 back to the witness one more time? 5 THE REPORTER: Okay. 6 (The last question was read) 7 MR. BONEZZI: Objection. 8 Go ahead and answer. 9 MR. JEFFERS: Objection. 10 A. No. And I think this clinical course of the 11 patient, how she got there, whether there was an opinion 12 about a delay or not, you outline the facts. The facts 13 are, you know, what her vital signs are, what her lab 14 returns were -- all, I assume, went with her transfer -- 15 and you try to include in your discharge summary the 16 pertinent significance. This is a complicated patient. 17 And I think summary -- I wouldn't include that in my 18 summary, because the medical record has that in there if 19 you later go back on it. You have nurses' notes and you 20 have the patient's record. So I wouldn't have included 21 that in my discharge summary because that's the matter 22 between the nurse and the doctor. And the real -- and 23 you know she didn't get antibiotics at a certain time, 24 whether you interpret it as delayed or not. And who 25 that's attributed to is another matter. I just give the CONTINENTAL COURT REPORTERS, INC. 87 1 facts related to the patient, period. 2 Q. (By Mr. Paris) Don't you think that a 3 miscommunication that results in the delay of 4 recognizing an infection is a critical piece of 5 information pertinent to that patient? 6 MR. BONEZZI: Objection. 7 MR. SCHOBERT: Objection. 8 MR. JEFFERS: Objection. 9 A. I think I would outline the findings I had and 10 when things were started or not started. But to make a 11 point in a complicated patient like this about "Nurse X 12 didn't call me there," really is not addressing the 13 medical case. It's trying to think that you'd be 14 sitting in a room with attorneys. You give the facts 15 independent of the attorneys. I would think that's a 16 lawyer giving the discharge summary, not a physician. 17 Q. (By Mr. Paris) From the time that 18 antibiotic -- when you suspect an infection and you 19 want -- postpartum infection and you want to 20 prescribe, let's say, IV Unasyn -- 21 A. Okay. 22 Q. -- in a hospital setting, what is the accepted 23 standard of care required in terms of length of time in 24 which that antibiotic should be administered and 25 delivered? CONTINENTAL COURT REPORTERS, INC. 88 1 MR. BONEZZI: Objection. 2 MR. JEFFERS: I don't follow the 3 question. 4 MR. BONEZZI: I don't either. 5 A. Is that from when I ordered it to when it was 6 given? 7 Q. (By Mr. Paris) Yeah. 8 A. So I write an order and then I want the 9 antibiotic given? 10 Q. Right. 11 A. And you're specifically asking for Unasyn? 12 Q. Yeah. What's the accepted standard of care 13 from -- what's the accepted time frame? 14 A. I don't think there's a defined accepted time 15 frame. I think what happens at most hospitals, by the 16 time the order is written, taken off, pharmacy makes up 17 the antibiotic -- because Unasyn, probably, is not on 18 their floor stock -- it will be -- it will not be sooner 19 than an hour. 20 Q. And if you order it stat? 21 A. I work at the largest medical center in the 22 world. "Stat" means you get it maybe in an hour -- 23 Q. Okay. 24 A. -- unless I specifically -- you know, it's 25 there stocked already. "Stat" would be an hour. They CONTINENTAL COURT REPORTERS, INC. 89 1 got to mix it. It's easy to say "stat." But you've got 2 to mix the antibiotics. You've got to weigh the -- you 3 know, it's not as straightforward as one might think. 4 And you want it labeled right. You don't want any 5 mix-ups. 6 Q. Have you ever been sued in malpractice before? 7 MR. BONEZZI: Objection. 8 A. Yes. 9 Q. (By Mr. Paris) How many times? 10 MR. BONEZZI: Objection. 11 A. Once that I'm aware of. 12 Q. (By Mr. Paris) In what circumstance? 13 A. Actually, twice. I will say twice. Once I 14 was named as part of the university. 15 And the other was a patient who had an 16 incomplete miscarriage, required a D and C. She had 17 several problems. And they basically said I never did 18 the operation or had her sign the consent. And the 19 patient had been seeing a lawyer who later left the 20 United States with a lot of money. In the State of 21 Texas, they're required even to give nuisance suits 22 priority in that setting, and it was later dismissed 23 with no merit. 24 I was involved in a case in Cleveland 25 where I was called for a vaginal delivery with a CONTINENTAL COURT REPORTERS, INC. 90 1 shoulder dystocia. The residents had done the delivery. 2 I was the attending on call. The patient had no 3 sequelae neurologically, and I believe there was a 4 settlement. And I was named as part of the university 5 but not individually. 6 There may be other suits I'm unaware of. 7 They're the only ones I've been called in on. 8 Q. Does magnesium sulfate have a tendency to 9 depress the heart rate? 10 A. Respiratory rate. 11 Q. Respiratory rate? 12 A. Yes. 13 Q. Okay. And a patient such as Beth Williams on 14 magnesium sulfate, what ranges would you expect to see 15 her respiratory rate? 16 A. Well, you know, in the normal respiratory 17 rate, I wouldn't want a respiratory rate below 10, and I 18 wouldn't want it above 30. But if you're at my 19 criterion with respiratory rates, it's real simple. If 20 the patient is talking, they're not mag. toxic, if 21 they're talking and breathing. If they're not talking, 22 then I'm concerned about toxic levels. 23 Q. And does Ativan -- if you know, does Ativan 24 have a tendency to suppress blood pressure? 25 A. It may indirectly if the patient's relaxed, CONTINENTAL COURT REPORTERS, INC. 91 1 their blood pressure's a little lower. 2 Q. And can that contribute to a patient's descent 3 into -- into shock? 4 A. I don't think Ativan, unless given in 5 non-therapeutic dosages, would do that at all. 6 MR. GORDON: Let's take a break. 7 MR. JEFFERS: Another break? We just 8 took one. 9 MR. GORDON: Let's take another one. 10 VIDEOGRAPHER: Off the record. It's 11 4:13 p.m. 12 (Recess from 4:13 p.m. to 4:16 p.m.) 13 MR. PARIS: I'd like to state on the 14 record if -- if -- 15 MR. BONEZZI: David, if you'd going to 16 ask if he has any other opinions or if there's a change 17 of opinions, I will absolutely notify you and give you 18 the opportunity to make further inquiries, if that was 19 your question. 20 MR. PARIS: Yes. That was precisely the 21 question. But I was going to include if he reads any of 22 these depositions. 23 MR. BONEZZI: Oh, no. I will, because 24 I'm going to send him other depositions. And if there 25 is an addition to his opinions or a subtraction to the CONTINENTAL COURT REPORTERS, INC. 92 1 opinions, I will notify you. If his opinions vary in 2 any way, I will notify you. And I would presume that we 3 could take whatever deposition that you deem necessary 4 telephonically. 5 MR. PARIS: Okay. Thank you very -- oh, 6 let's go back on the videotape, and I'll conclude. 7 VIDEOGRAPHER: On the record at 4:17 p.m. 8 MR. PARIS: Thank you, Doctor. I have no 9 further questions. 10 MR. JEFFERS: I have one. 11 Would you mark that, please? 12 (Exhibit No. 3 marked) 13 EXAMINATION 14 BY MR. JEFFERS: 15 Q. I'll talk here. 16 A. Okay. 17 Q. Showing you what's been marked as Deposition 18 Exhibit 3, that is the report that you sent to 19 Mr. Bonezzi, dated April 11st, 2001? 20 A. Yes, it is. 21 Q. And do you still stand by your statements in 22 that report? 23 A. Yes, I do. 24 Q. Correct? 25 A. Yes, I do. CONTINENTAL COURT REPORTERS, INC. 93 1 Q. Thank you. 2 MR. JEFFERS: That's all the questions I 3 have. 4 MR. SCHOBERT: No questions. 5 VIDEOGRAPHER: Ending the deposition at 6 4:18 p.m. with Tape 2. 7 (Deposition ended 4:18 p.m.) 8 _ _ _ _ _ 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CONTINENTAL COURT REPORTERS, INC. 94 1 CHANGES AND SIGNATURE 2 PAGE LINE CHANGE REASON 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CONTINENTAL COURT REPORTERS, INC. 95 1 CHANGES AND SIGNATURE 2 PAGE LINE CHANGE REASON 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CONTINENTAL COURT REPORTERS, INC. 96 1 I, HUNTER A. HAMMILL, M.D., have read the foregoing 2 deposition and hereby affix my signature that same is 3 true and correct, except as noted above. 4 5 6 HUNTER A. HAMMILL, M.D. 7 8 THE STATE OF ) 9 COUNTY OF ) 10 Before me, , on this day personally appeared HUNTER A. HAMMILL, M.D., known to 11 me (or proved to me on the oath of or through _____________) (description of identity 12 card or other document) to be the person whose name is subscribed to the foregoing instrument and 13 acknowledged to me that he/she executed the same for the purpose and consideration therein expressed. 14 15 Given under my hand and seal of office on this 16 day of , . 17 18 19 20 NOTARY PUBLIC IN AND FOR 21 THE STATE OF 22 My Commission Expires: 23 Job No. 01-35415 24 25 CONTINENTAL COURT REPORTERS, INC. 97 1 IN THE COURT OF COMMON PLEAS FOR THE STATE OF OHIO 2 COUNTY OF CUYAHOGA 3 4 MARK WILLIAMS, ETC., : PLAINTIFFS, : 5 : : 6 VS. : CASE NO. 406184 : 7 : PARMA COMMUNITY GENERAL : 8 HOSPITAL, ET AL., : Defendants : 9 REPORTER'S CERTIFICATION 11 ORAL VIDEOTAPED DEPOSITION OF 12 HUNTER A. HAMMILL, M.D. 13 MAY 31, 2001 14 I, Nancy S. Landry, RPR, RMR, Certified Shorthand Reporter in and for the State of Texas, hereby 15 certify to the following: 16 That the witness, HUNTER A. HAMMILL, M.D., was duly sworn by the officer and that the transcript of the 17 oral deposition is a true record of the testimony given by the witness; 18 19 That the deposition transcript was submitted on________________, 2001, to the witness or to the 20 attorney for the witness for examination, signature, and return to me by ______________________, 2001; 21 22 That the amount of time used by each party at the time of the deposition: 23 24 Mr. David M. Paris - 1 hour, 43 minutes. Mr. John W. Jeffers - 1 minute. 25 CONTINENTAL COURT REPORTERS, INC. 98 1 That pursuant to information given to the deposition 2 officer at the time said testimony was taken, the 3 following includes counsel for all parties of record: 4 Mr. David M. Paris and Mr. Harlan M. Gordon - 5 attorneys for the plaintiffs Mark Williams, etc. Mr. John W. Jeffers - attorney for defendant Parma 6 Community General Hospital Mr. Jeffery E. Schobert - attorney for the 7 defendants Dr. Hsieh and Physician Staffing. Mr. William D. Bonezzi - attorney for the defendants 8 Dr. Hahn and The Woman and Wellness Center. 9 I further certify that I am neither counsel for, related to, nor employed by any of the parties or 10 attorneys in the action in which this proceeding was taken, and further that I am not financially or 11 otherwise interested in the outcome of the action. 12 Further certification requirements pursuant to Rule 203 of the Texas Code of Civil Procedure will be 13 certified to after they have occurred. 14 15 Certified to by me on this ________ day of 16 _______________,_________. 17 18 _________________________________ 19 Nancy S. Landry RPR, RMR, CSR Texas CSR No. 5326 20 Expiration Date: 12/31/2002 Continental Court Reporters, Inc. 21 2777 Allen Parkway, Suite 600 Houston, Texas 77019 22 (713)522-5080 23 24 25 CONTINENTAL COURT REPORTERS, INC. 99 1 FURTHER CERTIFICATION UNDER TRCP RULE 203 2 3 The original deposition was/was not returned to the deposition officer on ; 4 If returned, the attached Changes and Signature page 5 contains any changes and the reasons therefor; 6 If returned, the original deposition was delivered to Mr. David M. Paris, Custodial Attorney; 7 That $________ is the deposition officer's charges 8 to the plaintiff, Mark Williams, Etc., for preparing the original deposition and any copies of exhibits; 9 That the deposition was delivered in accordance with 10 Rule 203.3, and that a copy of this certificate was served on all parties shown herein on and was filed 11 with the Clerk. 12 Certified to by me on this ________ day of 13 _______________, 2001. 14 15 _________________________________ Nancy S. Landry RPR, RMR, CSR 16 Texas CSR No. 5326 Expiration Date: 12/31/2002 17 Continental Court Reporters, Inc. 2777 Allen Parkway, Suite 600 18 Houston, Texas 77019 (713)522-5080 19 20 21 22 23 24 25 CONTINENTAL COURT REPORTERS, INC.