0001
 1                 IN THE COURT OF COMMON PLEAS
                      CUYAHOGA COUNTY, OHIO
 2   
     MARK WILLIAMS, etc.,      )
 3   Plaintiffs                )
                               )
 4   vs.                       ) CASE NO. 406184
                               )
 5   PARMA COMMUNITY GENERAL   )
     HOSPITAL, et al,          )
 6   Defendants                )
 7   
 8   
 9                  ORAL VIDEOTAPED DEPOSITION
10                     HUNTER HAMMILL, M.D.
11                        June 23, 2001
12   
13        ORAL VIDEOTAPED DEPOSITION OF HUNTER HAMMILL,
14   M.D., produced as a witness at the instance of the
15   Defendants William K. Hahn, Jr. M.D., Powers
16   Professional Corporation d/b/a Women and Wellness
17   Center and duly sworn, was taken in the above-styled
18   and numbered cause on the 23rd day of June, 2001,
19   from 9:30 a.m. to 10:47 a.m., before Vickie G.
20   Hildebrandt , Certified Shorthand Reporter in and for
21   the State of Texas, reported by computerized
22   stenotype machine at 7400 Fannin, Suite 950, Houston,
23   Texas.
24   
25   
0002
 1                         APPEARANCES
 2   
 3   FOR PLAINTIFFS:
 4        Mr. David M. Paris
          Nurenberg, Plevin, Heller & McCarthy
 5        1370 Ontario Avenue, First Floor
          Cleveland, Ohio  44113
 6   
     FOR DEFENDANTS WILLIAM K. HAHN, JR., M.D., POWERS
 7   PROFESSIONAL CORPORATION D/B/A WOMEN AND WELLNESS
     CENTER:
 8   
          Mr. William D. Bonezzi
 9        Bonezzi, Switzer, Murphy & Polito
          1400 Leader Building
10        526 Superior Avenue
          Cleveland, Ohio  44114-1491
11   
12   ALSO PRESENT:
13        Paul Richardson, Videographer
14   
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0003
 1   
 2                            INDEX
 3                                                    PAGE
 4   HUNTER HAMMILL, M.D.
 5   Examination by Mr. Bonezzi ....................    4
     Examination by Mr. Paris ......................   38
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0004
 1                  THE COURT REPORTER:  Are there any
 2   stipulations?
 3                  MR. BONEZZI:  No.
 4                  THE VIDEOGRAPHER:  June 22nd,
 5   9:30 a.m.  We're now on the record.
 6                    HUNTER HAMMILL, M.D.,
 7   having been first duly sworn, testified as follows:
 8                         EXAMINATION
 9       Q.    (BY MR. BONEZZI) Would you state your name
10   for the record, please?
11       A.    Hunter Hammill, M.D.
12       Q.    And, Dr. Hammill, where are we presently?
13       A.    We're in an office building in Houston,
14   Texas.
15       Q.    Doctor, this case is going to trial
16   starting this coming Monday.  Would you tell the
17   ladies and gentlemen of the jury why you will be
18   unable to appear at trial next week or possibly the
19   following week, please?
20       A.    About, I guess, a week and a half ago,
21   Houston was hit with a natural disaster, flooding
22   most of the hospitals, although not the building
23   we're in, and homes, and we've had chaos.
24       Q.    So you're unable to appear in Cleveland?
25       A.    That's why I haven't been on the road to
0005
 1   Cleveland.
 2       Q.    Okay.  Would you give me your professional
 3   address, please?
 4       A.    7400 Fannin, Suite 1160, Houston, Texas.
 5       Q.    You are a medical doctor; is that correct?
 6       A.    Yes.
 7       Q.    Do you have an area of specialty?
 8       A.    I'm board certified in OB/GYN infectious
 9   diseases -- correction.  I'm board certified in
10   OB/GYN, and I did a fellowship in OB/GYN infectious
11   diseases.
12       Q.    Doctor, could you tell us approximately how
13   many OB/GYNs are in the country who also have a
14   subspecialty in infectious disease?
15       A.    There's -- there's no more than two dozen.
16       Q.    In other words, there's about 24 -- maybe
17   24 obstetricians/gynecologists who also have a
18   subspecialty in infectious disease.  Is that what
19   you're saying?
20       A.    Tops.
21       Q.    Okay.  Would you be kind enough to give us
22   a little bit of information regarding your
23   background, please?  Tell us where you went to
24   medical school, college, fellowships, et cetera.
25       A.    I went to Boston College as an
0006
 1   undergraduate.  I went to Columbia College of
 2   Physicians and Surgeons for -- for medical school.  I
 3   did a year of internal medicine at Montefiore
 4   Hospital in Pittsburgh.  I did my residency in OB/GYN
 5   at the UCLA Medical Center in Los Angeles.  I did a
 6   two-year OB/GYN infectious disease fellowship with
 7   Dr. Feingold in Los Angeles, and I've been on the
 8   faculty at UCLA, Case Western Reserve and Baylor
 9   College of Medicine.
10       Q.    Do you presently hold any type of
11   appointments here in the Houston area, and if so,
12   what are they?
13       A.    I'm a clinical associate professor in the
14   departments of pediatrics, family medicine and rehab.
15       Q.    Now, Doctor, I want to talk just for a
16   moment about infectious diseases.  To what extent
17   presently do you actually practice in the field of
18   infectious diseases as it pertains specifically to
19   either obstetrical patients or gynecologic patients?
20       A.    About probably 60 to 70 percent of my
21   patients that are OB/GYN patients have -- are seeing
22   me because of some other infectious disease-related
23   matter such as they're pregnant and they have AIDS or
24   pregnant and have malaria, which would be uncommon,
25   some pregnancy variant or a gynecologic-related
0007
 1   infection.
 2       Q.    In your practice, do you manage patients or
 3   treat patients who have what are called postpartum
 4   infections?
 5       A.    Yes, I do.
 6       Q.    Doctor, please explain to us what a
 7   postpartum infection is, please.
 8       A.    Well, a postpartum infection would be
 9   febrile morbidity, which means you have a temperature
10   elevation.  You may have tenderness, and those would
11   be the clinical symptoms.  Sometimes you have pain,
12   and I subdivide them into two groups, those who have
13   had C-sections and those who have had vaginal
14   deliveries, but any infection related to the delivery
15   after the baby is born.
16       Q.    Now, the term "postpartum," what does that
17   mean?
18       A.    After the delivery.  Partum, the baby is
19   out.
20       Q.    Approximately how many patients, if you
21   know, have postpartum infections?
22       A.    Without antibiotics, if you had a C-section
23   while in labor, in some series, up to 40 percent of
24   patients would have febrile morbidity, so that's a
25   patient in labor and then they have a C-section
0008
 1   because the baby didn't fit, if you will, and then
 2   they have a fever.  It's an empiric approach.  If you
 3   have -- give prophylactic antibiotics, preventative
 4   antibiotics, to prevent infections in elective repeat
 5   C-sections, it can be less than 10 percent.  Then if
 6   you look at vaginal deliveries, the infection rate is
 7   usually less than 1 percent of vaginal deliveries.
 8       Q.    Okay.  This case involves a vaginal
 9   delivery; is that correct?
10       A.    Yes.
11       Q.    In those situations, what would you
12   estimate the percentage of patients who have
13   postpartum infections, what would it be with vaginal
14   deliveries only?
15       A.    Vaginal deliveries only, as I said, would
16   be less than 1 percent of the patients would have
17   what's called febrile morbidity where it was related
18   to the uterus as opposed to mastitis, a breast
19   inflammation, so the vaginal -- post vaginal delivery
20   infections are uncommon.
21       Q.    Can you tell us whether there are different
22   organisms, different bacteria, that can cause
23   postpartum infections in this class of patients that
24   you've just described?
25       A.    Yes, sir, and the most -- one of the
0009
 1   classics, although we fortunately don't see it
 2   as -- well, fortunately we don't see it too often, is
 3   if a patient had gonorrhea, was untreated and then
 4   had a temperature elevation, so an STD-related
 5   untreated item is one concern, but most of the
 6   patients, the infection --
 7       Q.    Excuse me.  "SDT" is?
 8       A.    Sexually transmitted disease.
 9       Q.    Thank you.
10       A.    Most of the patients that have postpartum
11   infections, it relates to the bacteria that are in
12   their vagina or, if you will, like we have on our
13   skin that for some reason ascends up into the uterus
14   and an infection starts.
15       Q.    Are you familiar with a bacteria that is
16   known as Group A beta hemolytic streptococcal
17   bacteria?
18       A.    Yes.
19       Q.    Can you tell us whether or not there are
20   certain patients who can develop Group A
21   streptococcal infections following delivery where the
22   delivery has been a vaginal delivery?
23       A.    That can occur.
24       Q.    What is the percentage or likelihood of
25   that occurring in those patients?
0010
 1       A.    Extremely rare.  This is an extremely
 2   rare -- and by -- you specifically said infection?
 3       Q.    Yes.
 4       A.    Where an infection develops and then we'd
 5   even extend that where a life-threatening infection
 6   develops.  I failed to mention -- and I'm just
 7   talking about the uterus.  We're not talking about
 8   episiotomy infections --
 9       Q.    No.
10       A.    -- and things like that.
11       Q.    And approximately what percentage of
12   patients develop Group A streptococcal infections
13   following a vaginal delivery?
14       A.    Well, it's -- it's extremely rare,
15   especially if you include infections where toxins are
16   released and the patients get very sick.
17       Q.    Can you quantify that in percentage terms?
18       A.    I've seen one verified case in my life.  My
19   associate, who's worked at the largest hospitals like
20   Charity Hospital and Jefferson Davis Hospital we had
21   here where we're doing combined 40,000 deliveries a
22   year, he rarely sees this, so the -- and if you look
23   at the Center for Disease Control, you know, if there
24   are -- I'd be surprised if there's more than ten
25   cases a year in the country where this type of
0011
 1   infection occurs, so it's extremely rare.
 2       Q.    When you say "extremely rare," I want to go
 3   back for a moment to your earlier comment that
 4   approximately 1 percent or less than 1 percent of the
 5   patients who have delivered vaginally have an
 6   infection.  I use that as my premise for this
 7   question.  Out of that 1 percent or less than
 8   1 percent, how many patients percentage-wise develop
 9   Group A strep infections?
10       A.    I can't give an exact percentage because
11   it's so small.  For example, in the system that I
12   worked in and continue to work in where at the county
13   hospital, we had 20,000 deliveries, the two private
14   hospitals, 10,000, and at the other private hospital,
15   6,000, so almost close to 36, 37,000 deliveries, if
16   we have one case of Group A strep, I can't figure out
17   the percentage of what 1 over 36,000 is, but it's
18   extremely rare.
19       Q.    I want to go back to your qualifications
20   for a moment.  Can you tell us whether or not at
21   least 50 percent or more of your time is spent in the
22   act of clinical practice of medicine?
23       A.    Yes, it is.
24       Q.    Do you currently hold any type of medical
25   licensures that allows you to practice medicine and
0012
 1   if so, where?
 2       A.    I'm licensed in the State of Texas, the
 3   State of California and the State of Ohio.
 4       Q.    Do you currently belong to any
 5   organizations within your field of specialty or
 6   expertise?
 7       A.    I'm a member of the American College of
 8   OB/GYN.  I'm a member of the OB/GYN Infectious
 9   Disease Society of America, and I'm a member of the
10   International OB/GYN Infectious Disease Society,
11   which is a different group.
12       Q.    Is there a difference, Doctor, if you know,
13   between the infectious disease specialty for
14   individuals who practice in internal medicine as
15   opposed to individuals whose primary practice is in
16   obstetrics and gynecology and if so, what is it?
17       A.    Well, the area of OB/GYN infectious disease
18   is much like pediatric infectious disease early on.
19   It doesn't have a specific board fellowship exam, so
20   the adult infectious disease has a separate board.
21   Pediatric infectious disease, only in the last ten
22   years, I believe, developed a separate board, so
23   that's one difference, and I guess the other -- the
24   big difference is since I work with a lot of adult
25   infectious disease doctors, is they don't -- it's
0013
 1   sort of a crossover because the adult infectious
 2   disease physicians don't routinely see the type of
 3   soft tissue infections you see in obstetrics and
 4   gynecology, and that's where the specialty evolved,
 5   so I'd say the big difference is we're usually called
 6   in on these complicated patients usually by other
 7   obstetrician/gynecologists whereas the internist
 8   adult ID person may occasionally be called in on
 9   these patients.
10       Q.    Okay.  Doctor, have you written in your
11   field of specialty?
12       A.    Yes, I have.
13       Q.    Have you had your writings published in
14   peer-reviewed journals?
15       A.    Yes, I have.
16       Q.    Can you tell us what a peer-reviewed
17   journal is?
18       A.    I can tell you what it's supposed to be.
19       Q.    That will be even better.
20       A.    It's supposed to be a journal where if you
21   submit an article, it's usually read -- read blinded,
22   meaning the person who wrote the article's name isn't
23   known to the reviewers, and it is -- just as a jury
24   of your peers, these are colleagues of your peers.
25   For example, if it was a cardiology journal, you'd
0014
 1   have a cardiologist reviewing the articles.  In my
 2   field, it would be obstetrician/gynecologists or
 3   obstetrician/gynecologists who do infectious
 4   diseases.
 5       Q.    Doctor, are you familiar with the term
 6   known as an exotoxin, E-X-O --
 7       A.    Yes, I am.
 8       Q.    Go ahead.  What is it, please?
 9       A.    An exotoxin, simply put, would be a
10   substance which is secreted outside of the cell.
11   Maybe it's sort of like exhaust fumes.  The car keeps
12   running, but there's stuff that's spewed out.
13       Q.    And how does an exotoxin cause problems
14   with a patient who has an infection or has developed
15   sepsis?
16       A.    Well, toxin, as the name would suggest,
17   toxic, toxins can do a variety of things.  One of the
18   more serious things, it can break down red cells.  It
19   can prevent phagocytosis, which is like the white
20   cells that eat the bacteria or destroy it, so toxins
21   are toxic to the -- to the body and it's like a
22   poison in the system and actually poisons a chain of
23   events, and it's almost like a waterfall.  It starts
24   off and then the waterfall builds momentum as the
25   flood occurs, to use a Houston analogy.
0015
 1       Q.    I asked you before if you were familiar
 2   with Group A strep.
 3       A.    Yes.
 4       Q.    To what extent is there an association
 5   between the presence of a Group A streptococcal
 6   bacteria and the release of exotoxins?
 7       A.    Well, there's an association and that's
 8   what Group A strep is known for, that it has the
 9   potential to release this toxin, life-threatening
10   toxin.
11       Q.    Now, why is it life-threatening?
12       A.    It's like a venomous snake, if you had a
13   venomous snake that had a lethal venom.  Even though
14   the amount of venom that's in the person that's
15   bitten, it has a cascade effect by -- with Group A
16   strep, it, if you will, poisons a lot of the
17   functions of the -- of the body.  It destroys red
18   cells.  It will destroy tissues like the liver, the
19   heart, the kidneys.  It will -- if you will, almost
20   like a flesh-eating bacteria that's common in the
21   press to describe it as, so it will destroy.
22       Q.    You are familiar with the term "necrosis,"
23   are you not?
24       A.    Yes.
25       Q.    To what extent will the destruction of soft
0016
 1   tissue play a role in the development of necrosis, if
 2   at all?
 3       A.    Well, soft tissue -- and by soft tissue, it
 4   could be fat on your arms or legs.  It could be
 5   something soft like the uterus as opposed to bone, if
 6   you will.  Now, soft tissue and necrosis, if you
 7   will, particularly in obstetrical and gynecologic
 8   infections, are a difficulty because as they become
 9   necrotic, as the tissue necroses or dies, the blood
10   supply to that area becomes walled off.  I like to
11   use the analogy it's like a freeway at rush hour.
12   Congestion occurs, and nothing moves into where you
13   want to go.
14       Q.    So, in other words, when you talk about
15   necrosis, once necrosis develops, it walls off the
16   ability of, for instance, antibiotics to be
17   delivered?
18       A.    Well, it's like this:  If you have blood
19   supply going to a site of tissue, once it's necrotic,
20   the blood vessels, the veins, the arteries, they're
21   not open.  Nothing gets in, and they gradually -- so
22   it's harder for the body's defenses to get to a
23   target site.  It's like a fort.
24       Q.    Now, Doctor, at my request, you reviewed
25   certain items that pertain specifically to this case,
0017
 1   have you not?
 2       A.    Yes.
 3       Q.    And without having you go through
 4   everything, can you tell me if you reviewed the
 5   records that were generated as a result of the
 6   June 24th through June 26th, 1999 confinement at
 7   Parma Community General Hospital of the decedent,
 8   Mary Beth Williams?
 9       A.    Yes, I did.
10       Q.    Did you review the transport records and
11   the records generated once she was confined at
12   University Hospitals on June 26th?
13       A.    Yes, I did.
14       Q.    Have you reviewed the deposition
15   transcripts of many of the experts in this case which
16   would have included Dr. Mark Martins?
17       A.    Yes, I did.
18       Q.    Dr. Neal Crane?
19       A.    Yes.
20       Q.    Dr. Keith Armatage?
21       A.    Yes.
22       Q.    Dr. Metha Deshan?
23       A.    I'm not sure I reviewed Dr. Deshan's.
24       Q.    Have you reviewed the deposition transcript
25   of the defendant, William Hahn?
0018
 1       A.    Yes.
 2       Q.    Have you reviewed the transcript of
 3   Dr. Martin Raff?
 4       A.    I believe I did, yes.
 5       Q.    Have you reviewed the publication -- strike
 6   that -- the -- the reports that were generated by
 7   those individuals who I've just mentioned?
 8       A.    You mean their depositions?
 9       Q.    No, the reports where they set forth their
10   opinions prior to their depositions.
11       A.    I don't believe I've seen those reports.
12       Q.    Okay.  As far as the records and the
13   reports and the depositions that have been sent, were
14   you able to form opinions in this case based upon the
15   review of those records?
16       A.    Yes, I have.
17       Q.    And were you able to form opinions that
18   pertain specifically to the cause of death of Mary
19   Beth Williams?
20       A.    Yes, I have.
21       Q.    Were you able to determine whether or not
22   William Hahn, the obstetrician who cared for Mary
23   Beth Williams from approximately 5:00 o'clock in the
24   afternoon on June 25th until the time in which she
25   was transported out to University Hospitals, met the
0019
 1   acceptable standards of care for a practicing
 2   obstetrician?
 3       A.    Yes, I've reviewed them.
 4       Q.    Okay.  I'm going to ask you this question
 5   first of all:  What did Mary Beth Williams die from?
 6       A.    She died from Group A strep toxin-releasing
 7   shock.
 8       Q.    Doctor, how are you able to conclude that
 9   the cause of death was directly related to a toxin
10   release from the Group A strep bacteria?
11       A.    I base that on the blood culture, the
12   autopsy report, which show the organism had been
13   cultured, and the systemic effect on the autopsy.
14       Q.    What do you mean by systemic effect
15   relative to the autopsy?
16       A.    That means she -- her kidneys shut down.
17   Her heart shut down.  Also specifically they describe
18   necrotic, as you were talking about earlier, dead
19   tissue within the uterus.
20       Q.    Now, let's talk about that for a moment.
21   Is that of significance to you that there were areas
22   within the uterus that demonstrated necrosis?
23       A.    Yes, because if the uterus was completely
24   normal, then I would have trouble postulating what
25   occurred and where it started from but in this case,
0020
 1   the necrotic areas of the uterus show that the
 2   infection, as with this type of bacteria, that was
 3   the nidus of the infection, the start.
 4       Q.    Okay.  Now, Doctor, if there were areas of
 5   necrosis or there was the presence of necrotic tissue
 6   in the uterus, do you have an opinion based upon
 7   reasonable medical probability whether or not, had
 8   antibiotics been delivered at any time, whether the
 9   antibiotics would have been effective in killing the
10   bacteria that were in the uterus?
11                  MR. PARIS:  Objection.
12       Q.    (BY MR. BONEZZI) Do you have an opinion?
13   Go ahead and answer.
14       A.    I have an opinion.
15       Q.    What is that opinion, Doctor?
16       A.    My opinion is that the necrotic tissue, the
17   dead tissue within the uterus, is, if you will, a
18   privileged site -- I use the -- use the expression
19   like a fortress -- and when the bacteria set up an
20   infection, unfortunately, in sort of an evil scheme,
21   the antibiotics, the white cells, lots of the things
22   that are part of the body's defenses, since the blood
23   supply is cut off, if you will, the roads are closed
24   or shut down, you don't get what you want to the
25   target site.
0021
 1                  The other problem is -- and sometimes
 2   confusing -- is that you may get a good blood level
 3   in your veins so if you're treating a heart
 4   infection, the blood gets to the heart valve, but in
 5   these kind of soft tissue infections in the uterus,
 6   one of the dilemmas is that the necrotic or dead
 7   tissue forms a barrier so that these anti-infective
 8   agents from the body and antibiotics that are ordered
 9   can't get to that site, and that's a big problem.
10       Q.    Doctor, as part of your review, did you
11   review the autopsy that was performed on behalf of
12   the family of Mary Beth Williams?
13       A.    Yes, I did.
14       Q.    Do you recall if there were any focal areas
15   of hemorrhage within the uterus as demonstrated or
16   described in the autopsy?
17       A.    Yes, there were.
18       Q.    And can you tell me or tell us whether
19   there were any abnormalities involving the
20   perimetrial soft tissue within the uterus?
21       A.    Yes, there were.
22       Q.    Now, could you explain to us the
23   significance of, first of all, the focal areas of
24   hemorrhage and then secondly the abnormalities within
25   the soft tissue of the lining of the uterus?
0022
 1       A.    Okay.  And I'll just say, to describe it
 2   anatomically, if I can --
 3       Q.    Please.
 4       A.    -- on the film, if I were to put my arms
 5   out -- I don't know if this is on camera -- and I was
 6   the uterus and these were the fallopian tubes and my
 7   white coat here was where the vessels came through,
 8   the perimetrium is next to the uterus and what
 9   happens is this gets -- the blood supply coming in
10   gets cut off and if I want the antibiotics to get to
11   my -- where my chest is, which would be the uterus,
12   it's cut off, and the fact that there was soft tissue
13   destruction and hematoma as there's bleeding which
14   may have been caused by the toxin lysing red cells
15   and tissue dissolving and blood vessels being closed
16   like a clogged highway, that, again, is more dead
17   tissue.  Just like if you get a bruise underneath
18   your skin, you have a bruise, that's -- but it's a
19   big bruise inside and it walls off, so there was a
20   large amount of tissue destruction which, from the
21   autopsy, you know, we're looking at sort of
22   afterwards, that had been destroyed.
23       Q.    Do you know what caused the destruction?
24       A.    The Group A strep toxin caused the
25   destruction.
0023
 1       Q.    Doctor, will the administration of
 2   antibiotics eradicate the toxin?
 3       A.    The toxin won't be killed by the
 4   antibiotics.
 5       Q.    Well, then, what's the purpose of
 6   administering antibiotics if, in fact, there is a
 7   belief that an infection exists?
 8       A.    Well, you don't know it's Group A strep.
 9   You don't even know there's a toxin release and one
10   of the things that occurs in obstetrical infections,
11   differing a little bit from the bladder infection or
12   spinal fluid infection or even routine sepsis -- and
13   I don't want to use the word "routine," but where the
14   bacteria in the blood -- is that the antibiotics
15   sometimes will suppress sepsis, meaning we know we
16   get a high blood level, high amount of antibiotics in
17   the blood, and we know from laboratory studies that
18   if you have "X" organism, it will be killed by "X"
19   bacteria at a certain level, and that's how we
20   correlate choosing antibiotics and that's how drug
21   companies make antibiotics and narrows the standards
22   to report to killing bacteria.
23                  One of the problems, again, in
24   obstetrical infections, the target tissue, meaning
25   like my tummy if I was the uterus, the antibiotics --
0024
 1   the root to the infection is cut off, if you will, as
 2   tissue is necrotic, and that's why surgeons drain
 3   things, so it's like -- and normally the uterus
 4   is -- can be like a self-draining abscess through the
 5   cervix, but not always, and that's why with necrotic
 6   tissue, you can't get the same levels, but we do give
 7   antibiotics to suppress sepsis and hopefully to get a
 8   small amount of antibiotics to where we want them to
 9   go, but until you -- you know, and fortunately, in
10   this case, there's an autopsy -- you don't know
11   what's going on.  It's empiric treatment.
12       Q.    In obstetrics, and specifically with you
13   treating patients with a suspected infection, do you
14   always know where the target of the infection happens
15   to be?
16       A.    Well, we use the if you hear hoofbeats,
17   it's probably horses, not zebras, so if you just had
18   brain surgery, you probably had a brain abscess.  If
19   I operate on your bladder, that, and in an
20   obstetrical case, it's usually the uterus, tubes and
21   ovaries.  Sometimes in a postpartum patient, it is
22   the breast; so it depends what's going on.  Depends
23   on a lot of background information.
24       Q.    In a case such as the one that we're here
25   on today, if antibiotics would have been delivered,
0025
 1   for instance, at or by 5:00 o'clock in the afternoon
 2   of June 25th, 1999, can you tell us whether or not
 3   the delivery of antibiotics would have had any effect
 4   on Mary Beth Williams' condition and then secondly,
 5   would it have changed the outcome in this case?
 6                  MR. PARIS:  Objection.
 7       A.    I don't think it would have had -- the only
 8   effect it might have had, it might have suppressed
 9   the bacteremia, the bacteria that might be in the
10   bloodstream.  It would not have affected the toxin;
11   and, again, the toxin is like a venom.  Once it's in
12   the system, you have a problem, and in retrospect,
13   having seen the autopsy report, with the necrotic
14   tissue, the antibiotics wouldn't have reached that
15   site.
16                  MR. PARIS:  Move to strike.
17       Q.    (BY MR. BONEZZI) Doctor, I'm going to be
18   asking you some opinion questions in this case for
19   the next couple of minutes, and I would ask that you
20   answer your -- the questions to a reasonable degree
21   of medical probability.  Will you do that?
22       A.    Yes.
23       Q.    Okay.  Now, you read the records, as you've
24   already testified?
25       A.    Yes.
0026
 1       Q.    And you would have been able to determine
 2   what the clinical presentation of Mary Beth Williams
 3   was from approximately 1550 or ten minutes till 4:00
 4   in the afternoon throughout the rest of the evening
 5   of June 25th and into the morning hours of the 26th,
 6   correct?
 7       A.    Yes.
 8       Q.    Can you tell us whether there were any
 9   changes in her clinical presentation between
10   approximately 4:00 o'clock in the afternoon until
11   approximately 4:00 o'clock in the morning, and if so,
12   what were those changes?
13       A.    Well, I would just qualify, I'd want to
14   look at the records specifically for the time.
15   However, as I recall, the patient had some blurred
16   vision, had some shakes, and I'm not sure if that's
17   the time framework when she had the temperature
18   elevation --
19       Q.    And do you recall --
20       A.    -- but that is my summary feeling as to
21   what went on.
22       Q.    Okay.  I want you to assume for purposes of
23   this question that she developed what has been called
24   shaking and shivering at approximately 1550 in the
25   afternoon.
0027
 1       A.    Yes.
 2       Q.    In retrospect, can you tell us what you
 3   believe, what your opinion is, relative to the cause
 4   of the shaking and the shivering?
 5       A.    In retrospect, this was an infection.
 6       Q.    Are you aware of why she was admitted to
 7   the hospital, by the way, on June 24th?
 8       A.    She was admitted -- my understanding is
 9   that she had some signs or stigmata of a
10   pregnancy-related hypertension syndrome or
11   pregnancy-induced hypertension and that's why they
12   wanted to expedite the delivery because PIH, as it's
13   called, is cured by the delivery usually and that is
14   a very serious, potentially life-threatening
15   condition if it progresses.
16       Q.    By the way, are you familiar with the term
17   "virulence"?
18       A.    Yes.
19       Q.    What is that as it relates to an infection
20   or sepsis?
21       A.    Virulence, I guess you could call it, is
22   how tough you're going to be.  Are you going to be
23   punched by George Forman or am I going to be
24   punched --
25       Q.    Me.
0028
 1       A.    -- by you, so it's sort of how tough, how
 2   strong.  Is a tank going to drive over you or a
 3   Volkswagen?  I mean, virulence is how terrible, how
 4   dangerous, if you will, in layman's terms.  That's
 5   how I describe it.
 6       Q.    Do you have an opinion in this case
 7   relative to the virulence of the Group A strep that
 8   ultimately caused the death of Mary Beth Williams?
 9       A.    This was a highly virulent organism, lethal
10   virulence.
11       Q.    Doctor, I want you to presume for purposes
12   of this question that a CBC or complete
13   white -- complete blood count was obtained at
14   approximately 5:00 o'clock in the afternoon on
15   June 25th --
16       A.    Yes.
17       Q.    -- and the white count was about 16.1 --
18       A.    Yes.
19       Q.    -- without a differential, all right?
20       A.    Okay.
21       Q.    I want you further to presume that another
22   CBC was obtained and the white count at approximately
23   2330 or 11:30 in the evening on June 25th had now
24   dropped to 4.6.  I want you further to presume for
25   purposes of this question that a differential was
0029
 1   obtained at 5:00 o'clock and a differential was
 2   obtained also at 11:30 or 2330 and that the
 3   differential demonstrated a left shift as it did
 4   previously in the day and also a further left shift
 5   at 11:30 in the evening, okay?  I want you to presume
 6   all of that for purposes of this question.  Are you
 7   able to extrapolate from that white count of 16.1 at
 8   approximately 5:00 o'clock in the evening -- and by
 9   the way, the left shift included bands which were
10   approximately 13 percent -- vis-a-vis or versus the
11   white count of 4.6 at approximately 11:30 p.m. with
12   bands that were as high as 52 percent.  Can you
13   extrapolate and tell us whether or not that provides
14   you, as a physician who specializes in obstetrics and
15   infectious disease, to determine the virulence of the
16   organism?  First of all, can you do it?
17       A.    Yes.
18       Q.    Tell us about it, please.
19                  MR. PARIS:  Objection.
20       A.    The fact that normally white cells are a
21   measurement, first of all, of how -- the body's
22   defenses and a 16,000 white count with what you call
23   the bandemia or left shift would be a sign of an
24   infection and normally if the white count were to
25   drop, we'd say that's a good sign because the
0030
 1   infection is getting better but in this particular
 2   case, the fact that the white count drops to a level
 3   and the -- if, as you said, the number of bands
 4   increases, in very serious, life-threatening
 5   infections, the body is so overwhelmed, its immune
 6   system doesn't work the same way and, if you will,
 7   the white cell producing system is in shock so
 8   instead of having an enormously high white count, you
 9   have an enormously low one, so, again, in this
10   clinical setting, in retrospect, this would suggest
11   that this was a virulent toxin that was able to
12   inhibit the body's defenses further and, if you will,
13   lead to the shock.
14       Q.    (BY MR. BONEZZI) For purposes of this
15   question, Doctor, I want you to presume that a
16   temperature was obtained on behalf of Mrs. Williams
17   at approximately 1930 or 7:30 in the evening and
18   there was a spike in her temperature to 101.6. I want
19   you to presume that for purposes of this question.  I
20   want you further to presume that there will be
21   testimony in this case that certain experts who are
22   providing testimony on behalf of the plaintiffs have
23   stated that antibiotics should have been given
24   shortly thereafter or after the temperature spike was
25   determined or detected, all right?
0031
 1       A.    (Nods head.)
 2       Q.    Would you accept that?
 3       A.    That they said this, yes.
 4       Q.    Do you have an opinion based upon
 5   reasonable medical probability, had antibiotics been
 6   administered, say, by 8:30 in the evening because of
 7   the temperature spike and because of other clinical
 8   presentations of the patient, whether antibiotics
 9   would have altered the outcome and prevented the
10   death of Mary Beth Williams?  Do you have an opinion?
11       A.    I have an opinion.
12       Q.    What is it?
13       A.    That it would not have altered the course.
14       Q.    Please explain that to us.
15       A.    Well, the -- if a patient has a vaginal
16   delivery -- and we see lots of patients with vaginal
17   deliveries that have fevers to 101 that are often, if
18   you will, ignored.  The white count doesn't come back
19   for a day.  The antibiotics aren't started and they
20   have fevers and white counts and then they start the
21   antibiotics even a day or two later, they live.  They
22   live.  This particular patient -- and I would daresay
23   many patients -- most patients with an infection like
24   this after a vaginal -- not like this -- a febrile
25   morbidity after a vaginal delivery would live even
0032
 1   without antibiotics.  Now, they might develop some
 2   inflammation and some pelvic pain, but they'd be
 3   alive.  In this particular case, what makes it
 4   difficult is this patient presenting -- presented
 5   with a syndrome which is life-threatening which is
 6   very commonly associated with death, the
 7   pregnancy-induced hypertension, and she was seen and
 8   evaluated for that -- I won't say common but
 9   far -- far more reported serious, life-threatening
10   condition of the pregnancy-induced hypertension, but
11   in this particular case, at a vaginal delivery for
12   unknown reasons, this particular Group A strep
13   colonized or was in her uterus and we see -- and even
14   that wouldn't be life-threatening, even that type of
15   infection.  However, this particular isolate released
16   its toxin, so the fact that it released the toxin is
17   what -- and is a toxin-releasing Group A strep,
18   whatever triggered that killed her, and the problem
19   also is that as the tissue is necrotic, even if it's
20   a small area, antibiotics don't get to that site so
21   if you're saying antibiotics could have gotten to the
22   site and killed the bacteria, what I'd say is the
23   necrotic area would have prevented the antibiotics
24   getting there, did prevent the antibiotics from
25   getting there and furthermore, when the toxin is
0033
 1   released, it's a cascade effect that antibiotics do
 2   not effect.
 3                  MR. PARIS:  Objection.  Move to
 4   strike.  Unresponsive.
 5       Q.    (BY MR. BONEZZI) I think it was very
 6   responsive, Doctor.  Thank you.
 7                  When the placenta is delivered
 8   following the birth of the infant, to what extent, if
 9   at all, does that have an impact on the lining of the
10   uterus?
11       A.    The placenta is like a big pie.  It's
12   actually almost the size of a pie and when -- and the
13   uterus is bigger, maybe this size (indicating), and
14   it shrinks down to maybe the size of both my fists
15   together and when the placenta is delivered, there's
16   an area that is raw, if you will, weeping, and the
17   blood vessels contract and that's why, when the
18   placenta is delivered, the blood vessels contract but
19   there's a raw surface and then that heals.  That
20   seals over.
21       Q.    Are you familiar with the term
22   "devascularization"?
23       A.    Yes, I am.
24       Q.    To what extent does the removal of the
25   placenta cause or develop an area of
0034
 1   devascularization in the uterus?
 2       A.    Well, what happens is -- and this is part
 3   of the design plan of why we're alive -- is as the
 4   uterus contracts down, those vessels constrict and
 5   that bleeding, raw area constricts and if you will --
 6   that's -- that's one of the things that is supposed
 7   to occur where that -- that area of bleeding from the
 8   placenta bed closes off.
 9       Q.    Can antibiotics, if administered, be
10   delivered to the area in which there is
11   devascularization?
12       A.    Well, they'd have to seep in and since the
13   antibiotics go through the bloodstream and they
14   weren't given directly into the uterus or into the
15   soft tissue, they would have trouble reaching a
16   devascularized area.
17       Q.    If there is a suspected infection, not
18   knowing what the organism is but believed to be in
19   the uterus, what would be the common or normal dosage
20   of the antibiotic?
21       A.    Well, it depends on the antibiotic.
22       Q.    Let's say penicillin.
23       A.    Penicillin you give in dosages of millions
24   of units.  Ampicillin you give in grams.  Some other
25   antibiotics you give in milligrams.
0035
 1       Q.    Let's take Ampicillin.
 2       A.    Okay.
 3       Q.    What would be the common or acceptable
 4   dosage to be given empirically --
 5       A.    It would range --
 6       Q.    -- for a suspected uterine infection?
 7       A.    It would range anywhere from 500 milligrams
 8   to 2 grams anywhere from every three to six hours.
 9       Q.    Can you tell us whether or not that dosage,
10   had it been given at 7:30, 8:30, 9:30, 10:30 on the
11   evening of June 25th, would have had an impact on the
12   likely, I guess, staying alive of Mary Beth Williams?
13   In other words, would she have died?
14                  MR. PARIS:  Objection.
15       A.    She would have died.
16       Q.    (BY MR. BONEZZI) Okay.  So, in other words,
17   even had what would have been considered the
18   appropriate degree or dosage of antibiotics, had it
19   been given to her at any time during the evening of
20   June 25th, would it have altered the outcome in any
21   way?
22       A.    No.
23                  MR. PARIS:  Objection.
24       Q.    (BY MR. BONEZZI) Okay.  Doctor, did you
25   review these records sufficiently enough to form an
0036
 1   opinion relative to whether or not Dr. William Hahn
 2   met the acceptable standards of practice for a
 3   practicing obstetrician?
 4       A.    Yes, I reviewed them.
 5       Q.    And do you have an opinion to a reasonable
 6   degree of medical probability whether, in fact, he
 7   did meet the acceptable standards of practice for a
 8   practicing obstetrician?
 9       A.    Yes, he did.
10       Q.    Doctor, you have talked about
11   pregnancy-induced hypertension, and what I want to do
12   now is just ask you a couple of questions about that,
13   okay?
14       A.    Okay.
15       Q.    For pregnancy-induced hypertension or the
16   preeclamptic/re-clamptic condition, do you give mag
17   sulfate?
18       A.    Yes, you do.  That's one treatment.
19       Q.    Okay.  In this particular case, you saw
20   that she had shaking and shivering at 3:50 in the
21   afternoon, correct?
22       A.    Yes.
23       Q.    Can you tell us whether or not the shaking
24   and the shivering could indeed be consistent with the
25   presence of pregnancy-induced hypertension or the
0037
 1   delivery of even mag sulfate?
 2       A.    Well, people can react to mag sulfate like
 3   that, although the -- when I approach patients, the
 4   most -- as a clinician, again, the most ominous thing
 5   would be if I had a lady with PIH, pregnancy-induced
 6   hypertension, then I was called and she was shaking,
 7   I'd be concerned she might be having a seizure which
 8   can occur post-delivery also.
 9       Q.    Well, would a seizure be caused as a direct
10   result of an infection, like a Group A?
11       A.    Only if you had a -- a brain abscess or
12   meningitis, but a uterine infection would not cause
13   the seizure.
14       Q.    Later on, she had a temperature spike,
15   we've already talked about.  Can you tell us whether
16   or not that is consistent with either the presence of
17   mag sulfate or is it consistent with PIH?
18       A.    Patients do not usually have a fever after
19   mag sulfate, although they could have a reaction
20   which would cause a fever.  On the other hand, the
21   more common scenario, if I had a patient with
22   pregnancy-induced hypertension and I was concerned
23   that that disease was progressing, you can get liver
24   necrosis, renal necrosis, and when tissue dies, fever
25   occurs, so if I had a patient having a seizure and a
0038
 1   fever and had PIH, that would be a -- higher on my
 2   list of concerns.
 3       Q.    Doctor, my last question for you is this:
 4   After putting everything together, after reviewing
 5   all of these records, reviewing the deposition, is it
 6   your opinion, based upon reasonable medical
 7   probability, that unfortunately the disease process
 8   was going to progress and that even had antibiotics
 9   been delivered, it would not have altered the
10   outcome?
11       A.    That's my opinion.
12                  MR. BONEZZI:  Nothing further.  Your
13   witness.
14                         EXAMINATION
15       Q.    (BY MR. PARIS) Doctor, my name is David
16   Paris, and I represent the Williams family.
17                  You have experience in diagnosing and
18   treating postpartum infections; is that right?
19       A.    Yes.
20       Q.    And it's generally accepted that a fever in
21   a postpartum patient over 101 degrees Fahrenheit is
22   considered a fever; is that right?
23       A.    Yes.
24       Q.    In fact, it's generally accepted that a
25   single temperature of 101 Fahrenheit or greater
0039
 1   within the first 24 hours of delivery constitutes a
 2   fever?
 3       A.    Absolutely.
 4       Q.    And this has been generally accepted in
 5   your professional circles for decades; is that right?
 6       A.    I would agree with that.
 7       Q.    Okay.  And certainly a spiking fever within
 8   the first 24 hours of delivery can be an important
 9   sign and symptom of a serious postpartum infection,
10   can't it?
11       A.    Yes.
12       Q.    And, Doctor, do you believe that
13   antipyretics such as Tylenol, Motrin, ice packs can
14   artificially bring down the fever?
15       A.    Over a short period of time, yes.
16       Q.    And when a doctor is evaluating a patient
17   for a potential postpartum infection, he ought to
18   determine if the patient's fever is being
19   artificially held down by the use of antipyretics,
20   shouldn't he?
21       A.    I would want to know that, yes.
22       Q.    Now, whether you're talking about patients
23   who have a C-section or a vaginal delivery, there are
24   criteria for general -- for genital tract infections
25   which are common to both categories of patients,
0040
 1   true?
 2       A.    Yes, there are some that are common.
 3       Q.    Fever is one common --
 4       A.    Yes.
 5       Q.    -- criteria?
 6                  Lab values such as a white blood count
 7   higher than 14,000 or greater than 15 percent bands,
 8   that's another criteria?
 9       A.    Yes.
10       Q.    And uterine or abdominal discomfort?
11       A.    Yes.
12       Q.    And these are criteria that you've been
13   using not only in your papers but in your own private
14   practice for 20 years?
15       A.    Absolutely.
16       Q.    Okay.  Obviously an infection can become
17   more serious and develop into a condition known as
18   sepsis?
19       A.    Yes.
20       Q.    And you've helped us understand what sepsis
21   is; is that right?
22       A.    Yes.
23       Q.    And in your opinion, the criteria for
24   sepsis includes positive blood cultures?
25       A.    Yes.
0041
 1       Q.    That is, with an organism growing?
 2       A.    (Nods head.)
 3       Q.    An elevated white blood count?
 4       A.    Well, yes, although the positive blood
 5   cultures is the -- the most crucial one, but I would
 6   agree with the elevated white count, yes.
 7       Q.    And bandemia?
 8       A.    Yes.
 9       Q.    Fever?
10       A.    Yes.
11       Q.    Chills?
12       A.    Yes.
13       Q.    Possibly hypotension?
14       A.    Yes.
15       Q.    Possibly tachypnea?
16       A.    Yes.
17       Q.    And tachypnea is what?
18       A.    You breathe fast.
19       Q.    And possibly tachycardia?
20       A.    Your heart rate goes fast, yes.
21       Q.    And the difference between sepsis and
22   septic shock is that sepsis progresses into septic
23   shock?
24       A.    Shock would be when your body can't handle
25   it and the -- if you will, the engine stops working.
0042
 1       Q.    You've just told Mr. Bonezzi that -- that
 2   your experience with Group A strep infections is very
 3   limited; is that right?
 4       A.    My experience with Group A strep is
 5   extensive, although I've only had one confirmed
 6   case --
 7       Q.    Okay.
 8       A.    -- because it's such a rare disease --
 9       Q.    Right.
10       A.    -- and that's -- the fact that I've seen a
11   case is extensive.
12       Q.    It's your opinion that the mortality rate
13   or the death rate is 100 percent in -- in cases of
14   toxin-releasing Group A strep in a post-delivery
15   mother?
16       A.    In this infection where it -- where it is
17   confirmed that that was the organism and a toxin was
18   released and the fact that the patient died
19   is -- is -- proves it.  If the patient didn't die,
20   they didn't have this disease.
21       Q.    So we're clear, it's your opinion that
22   mothers who have a toxin-releasing Group A strep
23   infection after the delivery will never survive?
24       A.    That's right.
25       Q.    Okay.  And the professional literature that
0043
 1   you are relying on to support that opinion is one
 2   from the 1800s --
 3       A.    No.
 4       Q.    -- written by Ignat Semilweiss, right?
 5       A.    No.  Ignat Semilweiss, the father of this
 6   discipline, even, that's -- you -- you asked me does
 7   Ignat Semilweiss -- was that one of the largest
 8   series, and this was pre-Pasteur where Group A strep
 9   was felt to be the cause of death.  Since that time,
10   there are no large series so --
11       Q.    I asked you that question in your
12   deposition --
13       A.    -- that's one of -- yes.  That's not the
14   sole.
15       Q.    The precise question that I asked you
16   was --
17                  MR. BONEZZI:  Excuse me.  What page is
18   that?
19                  MR. PARIS:  That's on Page 25 starting
20   at Line 12.
21       Q.    (BY MR. PARIS) I asked you whether you had
22   any statistics that would support the proposition
23   that there's a 100 percent death rate and I asked you
24   if you could point us to any studies that support
25   that and you reported the classic study written by
0044
 1   Ignat Semilweiss in the 1800s where they -- where
 2   they had upwards of 20 percent maternal death rate --
 3       A.    Right.
 4       Q.    -- in an organism they felt to be Group A
 5   strep; is that right?
 6       A.    That's right.
 7       Q.    Is that what you told me?
 8       A.    That's right --
 9       Q.    Okay.
10       A.    -- and that's how this field in Group A
11   strep infections in pregnancy -- he is, if you will,
12   like Pasteur.  That is the start of understanding
13   this disease.
14       Q.    When in the 1800s was that paper written?
15       A.    I'd have to check a reference to give you
16   the date, but it was in like -- between 1840 and
17   1870, as I recall.
18       Q.    And that paper really concluded that
19   significantly less than 100 percent of those patients
20   with this infection go on to die, right?
21       A.    No.  The patients who died were felt to
22   have Group A strep.  The patients who lived weren't
23   felt to have that.  This is, again, pre-Pasteur.
24   This is when the disease entity like this woman had
25   was described, women who develop this and die.
0045
 1       Q.    And, of course, this is long before
 2   the -- the antibiotic era?
 3       A.    Absolutely.
 4       Q.    Antibiotics weren't discovered and used
 5   until when, after the 1940s?
 6       A.    After World War II.
 7       Q.    So any patients who survived this Group A
 8   strep back in the 1800s survived it without
 9   antibiotics?
10       A.    Again, if they had toxin-producing Group A
11   strep, it's my opinion they didn't live.
12       Q.    The fact is, Dr. Hammill, you can't point
13   us to one good study which supports the statement
14   that 100 percent of the post-delivery mothers who
15   have Group A strep toxins released will die.  There's
16   no current study, similar study to that effect?
17       A.    The -- again, to harken back to the
18   classics of medicine, in the old days, a good doctor
19   was someone who made the diagnosis and it was
20   confirmed at autopsy.  This is similar to other
21   life-threatening conditions.  When it is verified at
22   autopsy, the fact that this patient died, she falls
23   into that group of lethal toxin-producing Group A
24   strep.
25       Q.    Is there a seminole study, Doctor, that
0046
 1   will tell us --
 2       A.    There is no seminole study because this is
 3   such a rare disease and no one can -- as I said, my
 4   experience, one delivery out of 36,000 so the
 5   fact -- there is -- there is one variable.  It's sort
 6   of the denominator/enumerator question.  You could
 7   say -- like you could say how do you define this.  In
 8   my experience, understanding the disease from
 9   Dr. Semilweiss on, is patients who develop this
10   condition are dead.
11       Q.    Thank you.
12                  The last time you authored anything
13   related to postpartum endometritis or postpartum
14   infections was in the early 1990s?
15       A.    It may have been, yes.
16       Q.    All right.  Did you know that you're not
17   the only expert that Dr. Hahn hired in this case?  Is
18   that right?
19       A.    I don't know how many experts he hired.
20       Q.    Well, have you been told that Dr. Hahn also
21   hired a board certified infectious disease expert by
22   the name of Dr. Martin Raff?
23       A.    I believe that name was mentioned.
24       Q.    You told me that you read his deposition?
25       A.    I don't know if I saw -- I read lots of
0047
 1   depositions.  I believe I read that one.
 2       Q.    Did you ever speak with Dr. Raff about this
 3   case?
 4       A.    No.
 5       Q.    You think you read his deposition --
 6       A.    I'd have to see if it's in my pile there.
 7       Q.    Your pile is, I think, downstairs in your
 8   office.
 9       A.    Or if you have it with you.
10       Q.    It was -- it was taken on June 5th.  Did
11   Mr. Bonezzi ever tell you or did you learn from his
12   deposition what Dr. Raff's opinions were about this
13   so-called 100 percent death rate you claim exists in
14   this disease process?
15       A.    I'd have to look at the record to
16   specifically --
17       Q.    Did you learn that in Dr. Raff's opinion,
18   patients with this organism do not die 100 percent of
19   the time?
20       A.    His experience may be different.
21       Q.    Did you learn that in Dr. Raff's opinion,
22   the survivability of patients like Beth Williams
23   depend on various factors and those positive factors
24   include a patient who's young has a better chance of
25   surviving this organism, a patient who is healthy, a
0048
 1   patient who is in the hospital at the onset of her
 2   symptoms, a patient who is in an urban hospital
 3   setting with ready access to infectious disease
 4   specialists or who's 20 minutes from a high level
 5   treatment center like University Hospitals?  Did you
 6   learn that from Dr. Raff's deposition?
 7       A.    I don't know if I --
 8                  MR. BONEZZI:  Objection.
 9       A.    -- I learned that from his, but I
10   will -- you want me to respond to that?
11       Q.    (BY MR. PARIS) I just want to know if you
12   learned that from reading his deposition.
13                  MR. BONEZZI:  I'm not sure that he
14   even got it.
15       Q.    (BY MR. PARIS) Okay.  I'm just basing my
16   questions on what I thought I heard you say in your
17   direct examination, sir.
18                  MR. BONEZZI:  But I'm not sure that I
19   sent it to him.
20       Q.    (BY MR. PARIS) Well, then, did Mr. Bonezzi
21   tell you that Dr. Raff testified that the delivery of
22   antibiotics to Beth before 11:30 p.m. on Friday night
23   may have altered the outcome in this case such that
24   the toxins may not have overcome her?
25       A.    He may have said that.  I don't agree with
0049
 1   it.
 2                  MR. BONEZZI:  For the record, I
 3   haven't provided him any testimony as it relates to
 4   Dr. Raff.
 5                  MR. PARIS:  I can only go on what I
 6   heard him say in his direct examination.
 7                  MR. BONEZZI:  But he didn't say
 8   anything about me providing him testimony.
 9       Q.    (BY MR. PARIS) Do you know that in
10   Dr. Raff's opinion, that some point during her stay
11   at Parma Hospital, if appropriate treatment had
12   begun, she was going to survive and the point where
13   she crossed over to where she was unlikely to survive
14   was 11:30 p.m. Friday night?  Did you know he said
15   that?
16                  MR. BONEZZI:  Objection.
17       A.    The -- if you're telling me he said that, I
18   have no reason to dispute it.
19       Q.    (BY MR. PARIS) Okay.  And so if Dr. Hahn's
20   other expert has expressed these opinions, you would
21   respectfully disagree with them?
22       A.    I would say I have much different
23   experience being a specialist in this area.  I don't
24   know if he's an internal medicine doctor that doesn't
25   deal with these patients too often.
0050
 1       Q.    But you disagree with him?
 2       A.    I would disagree with him, yes.
 3       Q.    And if plaintiffs' experts Dr. Jamofsky,
 4   Dr. Crane, Dr. Mark Martins -- and there's no
 5   question you read their testimony, right?
 6       A.    Yes.
 7       Q.    If they have opinions that Beth would have
 8   survived even though she had Group A strep toxins
 9   released in her system, you would disagree with them,
10   too?
11       A.    I and God would disagree with them.
12       Q.    Oh, you're on God's side in --
13       A.    Because she died.  She died.
14                  MR. BONEZZI:  Objection.  Move to
15   strike.
16       Q.    (BY MR. PARIS) I'm sorry.  Did you say you
17   were on God's side in --
18       A.    No.  I said she died.
19                  MR. BONEZZI:  Objection.  Move to
20   strike.
21       Q.    (BY MR. PARIS) All the experts in this case
22   are wrong except you.  Is that -- is that it?
23       A.    No.  I would say that their interpretation
24   and understanding of this disease entity may
25   be -- they may have less experience and they may see
0051
 1   less -- one of the points in this case isn't just
 2   that she had Group A strep.  The other issue and the
 3   point that may be missed through all of this is that
 4   this woman presented with a life-threatening
 5   condition of pregnancy-induced hypertension.
 6       Q.    Doctor, my question was are the other
 7   experts in this case wrong except for you?  And it's
 8   a simple yes or no answer.
 9       A.    Yes.
10       Q.    Okay.  They're wrong and you're not,
11   correct?
12       A.    That's my opinion.
13       Q.    Okay.  And as it relates to your time as an
14   expert witness, in the vast majority of medical
15   negligence cases, 70 percent -- 75 percent of the
16   time, you go to court with the doctors; is that
17   right?
18       A.    I wouldn't say I go to court with the
19   doctors.  It's uncommon that I have to go to trial.
20       Q.    Well, 75 percent of the time, you work for
21   the doctors?
22                  MR. BONEZZI:  Objection.  He doesn't
23   work for anybody.  He provides opinions.
24       A.    I would say that whether it's a 75 or
25   70/30, I review both cases, plaintiffs and
0052
 1   defendants.  There appear to be more cases, in my
 2   experience, that are referred to me and I will agree
 3   with that number that it is the defendants who are
 4   physicians.
 5       Q.    (BY MR. PARIS) So if you testified in your
 6   deposition that it was 75 percent of the time, you're
 7   not going to go back on that?
 8       A.    I'm not going back on that.
 9       Q.    Doctor, you authored a report in this case
10   which is five lines long; is that right?
11       A.    Yes.
12       Q.    You read Beth's prenatal records, the whole
13   Parma Hospital chart?
14       A.    Yes.
15       Q.    The University Hospital chart?
16       A.    Yes.
17       Q.    The autopsy report --
18       A.    Yes.
19       Q.    -- before you authored that and --
20       A.    Yes.
21       Q.    -- having read those couple of hundred
22   pages, the five lines that you wrote basically
23   expressed two opinions; is that right?
24       A.    I'd have to look at it to see if we put in
25   two --
0053
 1       Q.    Well, the one opinion was the accepted
 2   standard of medical care was met --
 3       A.    Yes.
 4       Q.    -- with regard to Beth and, two, her death
 5   was unpreventable?
 6       A.    Yes.
 7       Q.    And when you and I met the first time on
 8   June 7th, you hadn't read any of the depositions of
 9   the Parma Hospital nurses; is that right?
10       A.    Correct.
11       Q.    And you hadn't read the deposition of the
12   house officer, Dr. Shea?
13       A.    Correct.
14       Q.    And you hadn't even read the deposition of
15   Dr. Hahn, the man that hired you in this case; is
16   that right?
17                  MR. BONEZZI:  Dr. Hahn -- objection.
18   He did not hire him.
19       Q.    (BY MR. PARIS) You're an expert for
20   Dr. Hahn in this case, aren't you?
21                  MR. BONEZZI:  Dr. Hahn didn't hire
22   him, and you know better than that.
23       Q.    (BY MR. PARIS) I'm sorry.  Dr. Hahn is the
24   doctor that you are performing these services for; is
25   that correct?
0054
 1       A.    I --
 2                  MR. BONEZZI:  Objection.  Move to
 3   strike.
 4       A.    -- am hired, I guess, by the law firm that
 5   contacted me.
 6       Q.    (BY MR. PARIS) To render opinions on behalf
 7   of Dr. Hahn?
 8       A.    Yes.
 9       Q.    And you had not even reviewed Dr. Hahn's
10   testimony before you authored that opinion, right?
11       A.    That's true.
12       Q.    When did -- when did you read these
13   depositions?
14       A.    It was -- I'd have to look at the exact
15   date.  It was months ago or a long time ago.
16       Q.    No, no.  As of June 7th, you hadn't read
17   Dr. Hahn's deposition?
18       A.    Since then.  Oh, I thought you meant when
19   did I read --
20       Q.    No.  When did you read all this material?
21       A.    Between now and since then.  I had received
22   copies from the attorneys.
23       Q.    So sometime in the past two weeks?
24       A.    Yes, since I received them.  It's been
25   within the past two weeks.
0055
 1       Q.    Even though in your entire career you've
 2   only seen one patient with this toxin-releasing
 3   Group A strep infection, do you believe that you're a
 4   reliable authority on this subject?
 5       A.    Absolutely.
 6       Q.    And even though you haven't written
 7   anything on the subject of postpartum infections of
 8   the genital tract in seven or eight, nine years, you
 9   believe that you're still a reliable authority on
10   this subject?
11       A.    I've written a lot of books.  Currently I'm
12   fighting the largest infectious disease endemic in
13   the world.  That's why.  I'm treating AIDS patients.
14       Q.    That's HIV.
15       A.    Every day, every day I deliver patients.
16   I'm still practicing clinical medicine, and I will
17   deliver almost 200 patients a year.  I work at the
18   largest medical center in the world and in addition
19   to my academic training, I have the advantage of
20   being one of the busiest clinicians in infectious
21   diseases, so I would say not only am I qualified, I
22   may be more qualified because I actually see these
23   infections with the growing changes that occur with
24   organisms --
25       Q.    In this case --
0056
 1       A.    -- so I'm not just in a classroom or an
 2   office isolated.
 3       Q.    In this case, it's your opinion that Beth's
 4   infection definitely first manifested itself when her
 5   vital signs were erratically changing and they
 6   started the antibiotics.  Clearly, at that point, the
 7   Group A strep toxins were released, right?
 8       A.    I would say that toxins -- in retrospect,
 9   I'd have that opinion, yes.
10       Q.    And, of course, they started the
11   antibiotics at 11:30 a.m. on Saturday morning?
12       A.    I believe that's the time, yes.
13       Q.    And Group A strep, that organism is very
14   sensitive to penicillin or Unasyn which kills the
15   bacteria almost immediately?
16       A.    Absolutely, if it reaches the bacteria.
17       Q.    And if the bacteria is killed before it
18   releases the toxins and if the antibiotic gets to the
19   site of the infection, it stops the release of
20   toxins, right?
21       A.    We don't know what releases toxins.
22       Q.    No, no.  If the bacteria is killed before
23   it releases the toxins and if the antibiotics get to
24   the site of the infection before the release of
25   toxins, the toxins --
0057
 1       A.    The exotoxin --
 2       Q.    -- will not be released?
 3       A.    -- will not be released.  The endotoxins
 4   actually are released when the bacteria died.
 5       Q.    Exotoxins?
 6       A.    Exotoxins would be prevented.  The
 7   endotoxins are what are released when the bacteria
 8   dies.
 9       Q.    And, of course, the effect of no penicillin
10   or no Unasyn, no antibiotics, is that the bacteria
11   keeps growing and releasing toxins, correct?
12       A.    If the -- if the antibiotics get to the
13   bacteria and kill it, they don't produce exotoxins.
14       Q.    And the fact is that you believe that
15   before the toxin was released, Beth could have
16   survived this?
17       A.    If the toxin was never released, she'd be
18   alive today.
19       Q.    And you just don't know when the toxins
20   were released.  That's what you testified to in your
21   deposition, correct?
22       A.    Sometime during her course.
23       Q.    And the first toxins could have been
24   released after 7:30 p.m. Friday night, correct?
25       A.    I don't know when the toxins were released.
0058
 1       Q.    I asked you that exact same question in
 2   your deposition and you said they could have been
 3   released after 7:30.
 4       A.    I would agree with that.
 5       Q.    And the first toxins could have been
 6   released after 8:30 p.m. Friday night, correct?
 7       A.    Could have been.
 8       Q.    And you have no way of knowing one way or
 9   the other whether there's a probability that the
10   toxins were released prior to 8:30, right?
11       A.    Not necessarily because the pathology
12   report, with that degree of necrosis, would suggest
13   that with that extensive necrosis, that toxin release
14   in the nidus of infection, which was the uterus, were
15   being released even before any clinical symptoms
16   occurred because there was dead tissue there.
17       Q.    We're going to talk about the -- this
18   extensive necrosis that you claim exists in the
19   autopsy in a little while.
20                  Once a Group A strep toxin is released
21   into a person's bloodstream, you don't know how long
22   those toxins continue to produce harmful effects on
23   the body, do you?
24       A.    It's a cascade effect.  Once they're
25   released, they keep -- it triggers a response in the
0059
 1   human.  Yeah, I don't know exactly.  I don't think
 2   anyone knows.
 3       Q.    And you don't know if it's one toxin that
 4   causes all these problems or if it's the effect of a
 5   large amount of toxins that produces the septic shock
 6   and death, right?
 7       A.    That's true.
 8       Q.    And when I first took your deposition under
 9   oath a couple of weeks ago, you told me that the
10   Group A strep was found in Beth not through her blood
11   cultures but through testing of her uterus at
12   autopsy.  Do you remember telling me that?
13       A.    The autopsy report states Group A strep
14   pyogens as their diagnosis.  That's what I was
15   referring to at that time.
16       Q.    The fact of the matter is, is that the
17   bacteria, the Group A strep, was isolated in a blood
18   culture?
19       A.    Yes, I'm aware of that.
20       Q.    Okay.  So if you said otherwise in your
21   deposition, you were wrong?
22       A.    No.  I was referring to the autopsy report
23   where they -- where they state Group A strep
24   pyogenese was present.  That's what I was referring
25   to.
0060
 1       Q.    You agree with everyone in this case that
 2   Dr. Hahn did suspect Beth had an infection as early
 3   as 8:20 p.m. Friday night, right?
 4       A.    I agree he was -- that was in his
 5   differential.
 6       Q.    And that's why he ordered at least a urine
 7   culture and sensitivity and possibly a urinalysis; is
 8   that right?
 9       A.    Yes.
10       Q.    And even though Dr. Hahn was suspecting
11   Beth had an infection, it's your opinion that having
12   ordered tests like a urinalysis, a white blood count
13   with differentials -- "differentials" referring to
14   what, bands, neutrophils and metamyelocytes?
15       A.    Correct.
16       Q.    -- he was under no obligation to find out
17   what the results of those tests were?
18       A.    I wouldn't say he's under no obligation to
19   find the results of the tests.
20       Q.    He was under an obligation, then, to find
21   out the results of those tests, right?
22       A.    We follow up on our test results, yes.
23       Q.    If you order a test, you have to follow up
24   and find out what the results are?
25       A.    Yes.
0061
 1       Q.    Is that the obligation of a physician?
 2       A.    That's why we order the test, so we get the
 3   results.  Absolutely.
 4       Q.    That's the accepted standard of care; is
 5   that correct?
 6       A.    Yes.
 7       Q.    And is it your belief that a nurse who
 8   looks at these tests like a white blood count with
 9   differential has no obligation to tell the doctor who
10   ordered them that they are abnormal?
11       A.    No, I wouldn't say she has no obligation to
12   tell him that.
13       Q.    Well, if a nurse doesn't offer the
14   information, is the obligation of the doctor -- is it
15   the obligation of the doctor to ask?
16       A.    We ask.  The nurses aren't always
17   sophisticated enough to know -- to interpret all the
18   laboratory tests.
19       Q.    Okay.  So then the obligation really falls
20   squarely on the shoulders of the doctor?
21       A.    Yes.
22       Q.    Okay.  If Dr. Hahn felt strongly that
23   nursing negligence led to a nine-hour delay in the
24   treatment and diagnosis of Beth's infection, didn't
25   he have the obligation to point that out in the
0062
 1   hospital discharge summary that he dictated July 1st,
 2   1999?
 3       A.    When I dictate my discharge summaries, I
 4   dictate the facts of the case related to
 5   metabolically what occurred with the patient, and I
 6   would just state the facts of the record.  I would
 7   not give an opinion nor have I ever given an opinion
 8   when I dictated a discharge summary if negligence
 9   occurred or not.  I dictate the facts and then
10   whether it's negligent or not is -- is sorted out.
11       Q.    Well, how about just dictating in the
12   discharge summary the fact of a delay without
13   attributing it to negligence?  Did he have an
14   obligation to do that?
15       A.    I'm -- I would say that I'm not sure when
16   he was -- what was in his mind when he was dictating
17   the case.  If you dictate a case, you dictate their
18   hospital course.  Usually dictating a delay in
19   getting lab results -- if I dictated in every chart
20   there was a delay in getting lab results -- there's
21   always a delay and how you define "delay," is it an
22   hour, two hours?  Computers break down.  All the
23   computers in Houston are down.  There's a delay in
24   getting everything.
25       Q.    Well, Dr. Hahn --
0063
 1                  MR. BONEZZI:  Objection.
 2       Q.    (BY MR. PARIS) -- testified that there was
 3   a nine-hour delay, and I want to know from you
 4   whether -- if he didn't have that obligation to point
 5   that out in the discharge summary, did he owe that
 6   obligation of truthfulness to Beth's family?
 7                  MR. BONEZZI:  Objection.  Move to
 8   strike.
 9       A.    I can't comment on that, whether he owed an
10   obligation to her in that regard or not.
11       Q.    (BY MR. PARIS) Why not?
12       A.    Because I'm not sure if that's relevant to
13   what actually transpired.
14       Q.    Do you feel that it's acceptable for
15   Dr. Hahn to sweep that kind of alleged misconduct
16   under the carpet?
17                  MR. BONEZZI:  Objection.  Move to
18   strike.
19       A.    I'm not calling that misconduct in a delay
20   in that period or lack of delay in getting a lab
21   result.
22       Q.    (BY MR. PARIS) He's calling it misconduct.
23       A.    That's his opinion, not mine.
24                  MR. BONEZZI:  Objection.  Move to
25   strike.
0064
 1       Q.    (BY MR. PARIS) The fact that this
 2   condition, this Group A strep infection in a
 3   postpartum vaginal delivery is rare doesn't mean that
 4   you don't look for and try to diagnose and treat a
 5   postpartum infection, the symptoms of this condition,
 6   early on?
 7       A.    So I understand your question, if a patient
 8   prevents -- presents with an infection, would you
 9   treat it?  Yes.
10       Q.    Okay.  And the fact that it turns out to be
11   a rare infection, a rare organism, doesn't mean that
12   you're not going to treat the symptoms?
13       A.    No.
14       Q.    Okay.  You still have to treat the symptoms
15   when they present, right?
16       A.    Yes.
17       Q.    You spent some time talking to Mr. Bonezzi
18   about the necrosis that you saw in the autopsy in the
19   uterus.  There was necrotic tissue in the uterus.
20   How large an area of necrosis did you see?
21       A.    Well, they said it went to the perimetrium,
22   so that would be -- and it's not proportioned to the
23   size of my body, but if the uterus postpartum is
24   about the -- not quite as big as a football and it
25   spread all the way out to the blood vessels on the
0065
 1   side so -- "big" is a relative term.
 2       Q.    Well, let me ask you this:  Did it engulf
 3   the entire perimetrial tissues on both sides of the
 4   uterus?
 5       A.    It just says perimetrial tissues, but that
 6   means it spread all the way through the thickness of
 7   the lining of the uterus out to the blood supply.
 8       Q.    That's depth, but how about the length and
 9   width?
10       A.    Well, the anatomy, it's only a few
11   centimeters, sort of like the spinal column is very
12   narrow.  It's less than a millimeter, yet if the
13   bacteria cross that, you're dead, so the dimensions
14   aren't so important as the idea that it spread from
15   the lining of the uterus all the way into the area of
16   the perimetrium where the vessels are suggesting that
17   the uterus was being devascularized as the infection
18   progressed.
19       Q.    And the fact --
20       A.    The highways are being cut off.
21       Q.    Understood, and you made that analogy very
22   clear.  If the highways are cut off, that means the
23   antibiotics cannot come in --
24       A.    Absolutely.
25       Q.    -- to treat that localized area of
0066
 1   infection?
 2       A.    Correct.
 3       Q.    And if the highways are cut off, doesn't
 4   that also mean that the toxins don't have a way of
 5   getting out into the bloodstream?
 6       A.    Unfortunately, the toxins are smaller and
 7   seep out, and it's sort of like when you have a blood
 8   pressure cuff on.  The veins will -- will not cause
 9   blood return but the arteries are cut off, so the
10   toxins can seep and sort of eat through tissue and
11   then get to vessels and then spread, so I wish it
12   worked that way, but it doesn't.
13       Q.    And the fact that you claim that there is a
14   devascularization of the uterus after the placenta is
15   delivered which also impairs the ability of
16   antibiotics to get to the uterus; is that right?
17       A.    There's a devascularization to that bed,
18   that site where the placenta bed is raw.  That's why
19   women don't bleed after deliveries.
20       Q.    Well, but there is some bleeding after
21   delivery?
22       A.    Absolutely.
23       Q.    In this case, Beth had a moderate amount of
24   bleeding --
25       A.    And if the uterus --
0067
 1       Q.    -- didn't she?
 2       A.    Yes, and if the uterus didn't contract
 3   down, women would bleed to death --
 4       Q.    That's right --
 5       A.    -- after birth.
 6       Q.    -- but the fact that there is some moderate
 7   amount of bleeding which was noted in Beth is also
 8   evidence of the fact that there was some
 9   vascularization to the uterus?
10       A.    Absolutely, what's described as a normal
11   delivery bleeding.
12       Q.    Okay.  And to the extent that there was
13   some vascularization, there were some pathways,
14   roadways, highways, if you will, for antibiotics to
15   make their way to that site, correct?
16       A.    At that moment immediately after birth,
17   yes.
18       Q.    Bed was admitted to the hospital with
19   preeclampsia that was characterized as mild.  Is that
20   true?
21       A.    Yes, I believe that's true.
22       Q.    Was that a severe form of preeclampsia?
23       A.    I don't use the gradations mild, moderate,
24   severe because this is a disease that can progress
25   rapidly and once you've reached severe, you're in
0068
 1   trouble, so you either have PIH or not.  It's like
 2   being --
 3       Q.    Mr. Bonezzi asked you to characterize the
 4   virulence of this by extrapolating her different lab
 5   values between 5:00 p.m. and 11:30 p.m.  Do you
 6   recall that?
 7       A.    Yes.
 8       Q.    And you -- it was your opinion, based upon
 9   those lab values, that there were definite signs of
10   infection based upon those lab values that would
11   concern you; is that right?
12       A.    Yes.
13       Q.    I mean, you would be concerned with lab
14   values like that?
15       A.    Absolutely.
16       Q.    Yet, when I asked you that question on
17   Page 53 of your deposition and continuing into
18   Page 54, I asked you retrospectively to characterize
19   the severity of her infection at 11:30 and I asked
20   you to take into consideration those labs and -- and
21   anything else you wanted to take into consideration,
22   you ended the answer of that question by saying, "At
23   that point, based on what I read, I would not suspect
24   that this patient had a life-threatening infection"?
25       A.    Absolutely.
0069
 1       Q.    Okay.
 2       A.    Especially --
 3       Q.    Retrospectively?
 4       A.    -- light-threatening, you know.
 5       Q.    Thank you very much, Doctor.  I don't have
 6   anything further.
 7                  MR. BONEZZI:  No further questions,
 8   Doctor.  I thank you very much, sir.
 9                  THE VIDEOGRAPHER:  It's June 22nd,
10   10:47 a.m.  We are now off the record.
11                  (Proceedings concluded at 10:47 a.m.)
12   
13   
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22   
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25   
0070
 1        I declare under penalty of perjury that the
 2   foregoing is true and correct.
 3   
 4   
 5                            HUNTER HAMMILL, M.D.
 6   
 7   
 8        SUBSCRIBED AND SWORN TO BEFORE ME, the
 9   undersigned authority, by the witness, HUNTER
10   HAMMILL, M.D., on this the       day of             ,
11          .
12   
13   
14                           NOTARY PUBLIC IN AND FOR
15                           THE STATE OF
16   
17   My Commission Expires:
18   
19   
20   
21   
22   
23   
24   
25   
0071
 1   STATE OF TEXAS
 2   COUNTY OF HARRIS
 3   
 4                    REPORTER'S CERTIFICATE
 5      ORAL VIDEOTAPED DEPOSITION OF HUNTER HAMMILL, M.D.
 6                        June 23, 2001
 7   
 8        I, the undersigned Certified Shorthand Reporter
 9   in and for the State of Texas, certify that the facts
10   stated in the foregoing pages are true and correct.
11        I further certify that I am neither attorney or
12   counsel for, related to, nor employed by any parties
13   to the action in which this testimony is taken and,
14   further, that I am not a relative or employee of any
15   counsel employed by the parties hereto or financially
16   interested in the action.
17        SUBSCRIBED AND SWORN TO under my hand and seal
18   of office on this the       day of                  ,
19         .
20   
21   
22                             Vickie G. Hildebrandt, CSR
                               Texas CSR 1363
23                             Expiration:  12/31/01
                               UNITED-WOMACK REPORTING
24                             (713)426-0400
25