1 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 TONI L. BIANCHI, Executrix of the Estate of FRANCES R. 4 BRONCACCIO, Deceased, 5 Plaintiff, 6 -vs- CASE NO. 370551 7 8 KAISER FOUNDATION HEALTH PLAN OF OHIO, et al., 9 Defendants. 10 11 - - - - 12 Deposition of JOSEPH A. LAHORRA, M.D., taken as 13 if upon cross-examination before Laura L. Ware, a 14 Notary Public within and for the State of Ohio, at 15 Bonezzi, Switzer, Murphy & Polito, 1400 Leader 16 Building, 526 Superior Avenue, Cleveland, Ohio, at 17 10:10 a.m. on Friday, March 9, 2001, pursuant to 18 notice and/or stipulations of counsel, on behalf of 19 the Plaintiff in this cause. 20 21 - - - - 22 WARE REPORTING SERVICE 23 21860 CROSSBEAM LANE ROCKY RIVER, OH 44116 24 (216) 533-7606 FAX (440) 333-0745 25 2 1 APPEARANCES: 2 Tobias J. Hirshman, Esq. Linton & Hirshman 3 Hoyt Block Building - Suite 300 700 West St. Clair Avenue 4 Cleveland, Ohio 44113 (216) 781-2811, 5 - and - 6 Mark W. Ruf, Esq. 7 Hoyt Block Building - Suite 300 700 West St. Clair Avenue 8 Cleveland, Ohio 44113 (216) 687-1999, 9 On behalf of the Plaintiff; 10 Susan M. Reinker, Esq. 11 Bonezzi, Switzer, Murphy & Polito 1400 Leader Building 12 526 Superior Avenue Cleveland, Ohio 44114 13 (216) 875-2767, 14 On behalf of the Defendants. 15 16 17 18 19 20 21 22 23 24 25 3 1 JOSEPH A. LAHORRA, M.D., of lawful age, 2 called by the Plaintiff for the purpose of 3 cross-examination, as provided by the Rules of Civil 4 Procedure, being by me first duly sworn, as 5 hereinafter certified, deposed and said as follows: 6 CROSS-EXAMINATION OF JOSEPH A. LAHORRA, M.D. 7 BY MR. HIRSHMAN: 8 Q. Good morning. 9 A. Good morning. 10 Q. We introduced ourselves. For the record, I'll 11 introduce myself again. I'm Toby Hirshman. 12 A. Toby Hirshman. 13 Q. And I'm here to take your deposition in a case where 14 you've been identified as an expert witness. And 15 the usual procedure is by having you identify 16 yourself, so let's start there if we could. 17 A. I'm Joseph Anthony Lahorra. 18 Q. And you're a cardiothoracic surgeon? 19 A. Yes. 20 Q. In Cleveland? 21 A. Yes. 22 Q. Give me your home address, if you would. 23 A. 180 Fox Hollow Drive, it's two words, Number 202, 24 and that's Mayfield Heights, Ohio, 44124. 25 Q. I have a copy of your CV. You don't have one in 4 1 front of you. 2 A. No. 3 Q. But one is being copied for you. I don't have a lot 4 of questions for you from it, but I do have a few. 5 The first one being, it appears that there's three 6 work addresses that you've identified, one is at 7 Parma Community Hospital, one is at Hillcrest 8 Medical Office Building, and the third one is at The 9 Cleveland Clinic Foundation? 10 A. Right. 11 Q. Why don't you give me some idea as to how your time 12 is split between them both in terms of amounts of 13 time and what you do from each address. 14 A. The vast majority of my work is done at Parma. I'd 15 say maybe 80 percent, 20 percent probably at 16 Hillcrest Hospital. 17 Q. What about the Cleveland Clinic? 18 A. I'm on the staff there, but I don't do any of my 19 clinical work there. 20 Q. You're on the staff. You're on the staff by virtue 21 of some other status or -- 22 A. No, I'm a full member of the staff of thoracic and 23 cardiovascular surgery, but I work on the outside. 24 Q. Okay. Hillcrest is part of The Cleveland Clinic 25 system? 5 1 A. Correct. 2 Q. That's the issue I guess I was directing myself 3 towards. So it's through your status as having 4 privileges at Hillcrest Hospital that you are part 5 of The Cleveland Clinic system? 6 A. No. It's more the reverse. We -- I joined The 7 Cleveland Clinic and that allowed me to begin 8 working at Hillcrest Hospital, and I had been 9 working at Parma previously and continued to do so. 10 Q. All right. So prior to Hillcrest being taken over 11 by The Cleveland Clinic, you didn't have 12 privileges -- 13 A. Did not. 14 Q. -- at Hillcrest, all right. What's the setup in 15 terms of organizationally The Cleveland Clinic as to 16 why certain people are doing cardiothoracic surgery 17 at the facility downtown on Euclid and whether 18 you're all part of the same department and 19 communicate with one another, I guess is really the 20 issue I'm directing myself towards? 21 A. We're all part of the same department. 22 Q. Do you go to joint meetings of the Cardiothoracic 23 Surgery Department of The Cleveland Clinic? 24 A. Yes. 25 Q. And so how often do you actually spend time at The 6 1 Cleveland Clinic Foundation facilities downtown? 2 A. Roughly once every two months. 3 Q. What kind of meetings are -- is that a meeting sort 4 of a situation? 5 A. We have a staff meeting. 6 Q. And what's the nature of your status at The 7 Cleveland Clinic, staff surgeon, staff physician? 8 A. Yeah. 9 Q. Are you in any way under the direction and control 10 of -- who's head of the department, is it Cosgrove? 11 A. Toby Cosgrove. 12 Q. Is he responsible for what you do or are you 13 independent of him? 14 A. He's my boss. 15 Q. I used to practice law in West Virginia. How long 16 did you live in Welch? 17 A. Probably about two weeks. It wasn't very long. 18 Q. Great place to visit. 19 A. I actually have visited. 20 Q. It's an interesting place, I'll tell you. 21 A. Yeah. 22 Q. I'm not going to belabor the CV. I've seen guys go 23 for two, three hours on a CV. I don't intend to do 24 that. I could never figure out why anybody would do 25 it. But I note that you had a research project that 7 1 you seem to have been involved in from 1990 to 1992? 2 A. Correct. 3 Q. Surgical cardiovascular research unit, Mass. General 4 in Boston, and I notice that you also were 5 simultaneously doing a residency at University 6 Hospitals? 7 A. Right. 8 Q. Tell me about how that worked. 9 A. Well, I was doing my residency in general surgery at 10 University Hospitals and was awarded a scholar -- a 11 surgical research fellowship which was fully 12 supported by the department and through which I 13 could do research anywhere I chose to, and so I was 14 doing my research at Mass. General but was still 15 part of the residency at University Hospitals. 16 Q. So essentially an externship, you were physically 17 absent from Cleveland for those two years? 18 A. That's correct. 19 Q. And you were doing this research fellowship, I 20 guess, in a different sense of the word, then 21 fellowship subsequent to residency? 22 A. Right. It was a nonclinical fellowship. 23 Q. And you did that for two years and got credit for it 24 towards your residency requirements? 25 A. No, it's above and beyond the requirements for the 8 1 residency. 2 Q. So did your residency extend longer than -- it looks 3 like it goes from '88 to '94. Is that longer than a 4 straight arrow residency would be if you had just 5 started and finished? 6 A. Yes, it's longer by two years. 7 Q. Okay. So that accounts for that? 8 A. Right. 9 Q. I notice you have staff appointments, in addition to 10 the three hospitals that we talked about, Parma 11 Community, Hillcrest and The Cleveland Clinic, at 12 St. Vincent. Do you ever do any work there? 13 A. Very little. Very little, at this point. 14 Previously we had been very busy there. 15 Q. Well, let's say since January of 2000, have you done 16 any cases there at all? 17 A. Some, not many. 18 Q. And tell me a little bit about what your 19 relationship was with University Hospitals from '97 20 to 2000. 21 A. I had clinical privileges there, I was on staff. 22 Q. Did you do any work or any considerable amount of 23 work out of University Hospitals? 24 A. Very little. 25 Q. All right. I've got a bibliography of yours, which 9 1 is five publications in length. Is that your 2 complete list of contributions to the medical 3 literature? 4 A. Yes. 5 Q. So you've written nothing on aortic dissection? 6 A. No. 7 Q. And this CV is your current CV? 8 A. May I look at it? 9 Q. Absolutely. 10 MS. REINKER: Here. 11 A. Yes, this is current. 12 Q. Tell me, if you would, a little bit about the nature 13 of your practice. I understand you're a 14 cardiovascular -- are you a cardiothoracic surgeon 15 or a cardiovascular surgeon and is there a 16 difference? 17 A. I am a cardiothoracic surgeon in the sense that I do 18 cardiac surgery, and that is surgery for the heart 19 and great vessels, and I do thoracic surgery, 20 noncardiothoracic surgery, which is pulmonary and 21 esophageal work. I think cardiovascular, to me, 22 just implies that you may not do thoracic, 23 noncardiac thoracic. I do not do peripheral 24 vascular surgery. 25 Q. So you do cardiovascular work? 10 1 A. Yes. 2 Q. And you do thoracic work? 3 A. Correct. 4 Q. And you don't do peripheral vascular work? 5 A. Yes. 6 Q. What percentage of your surgical practice would you 7 say is cardiac specifically? 8 A. 80 percent. 9 Q. And my guess is that would be primarily coronary 10 artery grafting procedures and valve replacements? 11 A. Yes. 12 Q. And that's 80 percent. Now, what would the other 20 13 percent be? 14 A. Pulmonary resections. 15 Q. Can you give me a number of how much of it is 16 pulmonary in nature? 17 A. Of that 20 percent, a majority of it is pulmonary. 18 Q. So that's mostly patients with cancer that need a 19 resection? 20 A. Lung cancer, interstitial lung disease, those types 21 of problems, and a small percentage would be 22 esophageal. 23 Q. So we haven't yet talked about great vessels. At 80 24 percent cardiac, we've got how much pulmonary, would 25 you say? 11 1 A. Oh, I said about 15 percent, maybe 18 percent. 2 Q. At least two percent -- 3 A. The esophageal. 4 Q. Esophageal. Where do we put great vessels? 5 A. I would include that with -- 6 Q. Cardiac? 7 A. Cardiac. 8 Q. So let's try to break that out a little bit, if we 9 can. How much of your practice deals with the great 10 vessels, with taking care of problems pertaining to 11 the great vessels? 12 A. Probably two percent. 13 Q. All right. And by the great vessels, one of them 14 would be the aorta? 15 A. Yes. 16 Q. And I suppose we're also talking about, what, the 17 vena cava? 18 A. Very, very rarely. 19 Q. What other vessels, besides the aorta, would come 20 under that rubric, if any? 21 A. You may have to deal with the pulmonary artery. 22 Q. Okay. So from time to time you see patients with 23 aorta related problems? 24 A. Yes. 25 Q. And those would primarily be, what, aneurysms and 12 1 dissections? 2 A. Correct. 3 Q. Can you tell me how many times in your career, 4 starting with your -- let's start at a time that's 5 meaningful to start with, which would presumably be 6 the time of your beginning of your cardiothoracic 7 residency. 8 A. Uh-huh. 9 Q. I mean, your general surgery residency would not be 10 a time when you'd see many aortic dissections, I 11 assume? 12 A. That's correct. 13 Q. Okay. So let's start with the beginning of your 14 cardiothoracic residency. How many cases have you 15 seen of aortic dissection, as best you can 16 estimate? 17 A. I don't know exactly, but I would estimate somewhere 18 between a dozen and 20. 19 Q. And that's how many years, you're talking about ten 20 years? 21 A. The cardiothoracic residency was two. 22 Q. That's two, okay. So we're talking about seven 23 years? 24 A. About five years, actually. 25 Q. Five years, okay. How do those cases -- is there a 13 1 typical way that they present in terms of how they 2 get through the system to you, do they usually come 3 through an emergency room? 4 A. Typically acute presentations, yes, through the 5 emergency room. 6 Q. So I take it of these 12 to 20, some are acute 7 dissections, some are chronic? 8 A. Some are chronic. 9 Q. Are most of them acute? 10 A. I would say yes. 11 Q. So let's take a moment to talk about the difference 12 between acute and chronic. How would you 13 differentiate the two? 14 A. Well, they're differentiated purely on time of 15 presentation. An acute dissection presents within a 16 short period of time of the actual event. Chronic 17 dissection is one that has persisted over time, and 18 so that's the major difference is a time 19 difference. 20 Q. Is one type more likely to present with pain than 21 the other? 22 A. The acute dissection. 23 Q. So chronic dissections are frequently dissections 24 that present without pain? 25 A. They may. 14 1 Q. All right. Now, how does one know it's a chronic 2 dissection if it presents without pain? My guess is 3 you see these folks and there may or may not be a 4 known history of that dissection having existed 5 previously in time. How is it, as you sit here, 6 that you can say that X percent of my cases that 7 I've seen are acute and X percent are chronic? 8 A. I don't understand that question. 9 Q. Well, if somebody presents to you with a chronic 10 dissection, which they don't realize until they stop 11 perfusing their arm or they don't realize until they 12 stop perfusing their leg or they don't realize until 13 they stop perfusing their brain and present with a 14 syncopal episode or something like that, how is it 15 that you establish that this is a condition that's 16 existed for an extensive period of time? 17 A. Well, in my experience the chronic dissections, most 18 of the ones I have dealt with, very often it's an 19 incidental finding. 20 Q. So you're working them up for something that has 21 absolutely nothing to do with -- 22 A. It may not, correct, correct. In other words, a 23 chronic dissection would not present with new onset 24 of limb ischemia or some of the things you 25 mentioned. In my experience, the chronic 15 1 dissections I see very often have been evaluated for 2 some other problem. 3 Q. So it's fair to say the difference between an acute 4 and a chronic dissection is solely a matter of the 5 time at which it's diagnosed? 6 A. Well, by the definition, yes. 7 Q. So if there's a group of patients with chronic 8 dissections that don't present with pain, the only 9 way they really differ from the acute dissections is 10 that they don't present to a doctor at the time of 11 the initial tear; fair statement? 12 A. They, in all likelihood, had pain previously, but as 13 a chronic dissection may not have pain now. 14 Q. I'm not engaging in a discussion of fiction to 15 suggest that there are dissections of the aorta that 16 occur that are without pain? 17 A. Okay. 18 Q. Am I? 19 A. I don't know. 20 Q. Well, I guess you're the one who's in a position to 21 tell me. I mean, I'm not a doctor, I'm a lawyer. I 22 can read, but I don't have experience dealing with 23 these entities, but from my reading I've read in 24 various places that there are certain folks who 25 present with dissections of the aorta who present 16 1 without pain. Am I reading fiction or am I reading 2 something you can agree with? 3 MS. REINKER: Objection. He doesn't 4 know if you found that in a fiction text or 5 not. 6 A. It's very rare to not present with pain. 7 Q. But it happens? 8 A. It can. 9 Q. Okay. Do you have any figures that you can share 10 with me as to how often dissection occurs without 11 pain? 12 MS. REINKER: You're talking chronic 13 now? 14 MR. HIRSHMAN: We're talking about 15 dissections, period, aortic dissections. 16 MS. REINKER: Well, you're asking him 17 about chronic? 18 MR. HIRSHMAN: We're talking about 19 aortic dissections. We also talked about the 20 difference between chronic and acute, so I 21 think we understand each other. 22 A. It's very rare to have no pain in an aortic 23 dissection, acute aortic dissection. 24 Q. Can you give me some figures as to how rare? 25 A. I would say probably in the range of maybe 10 17 1 percent of cases. 2 Q. Is that across the board acute and chronic, as far 3 as you know? 4 A. I'm referring to an acute aortic dissection. 5 Q. So 10 percent of acute aortic dissections may 6 present without pain. What about chronic? 7 A. I don't know. 8 Q. All right. Of the 12 to 20 that you have seen -- 9 A. Uh-huh. 10 Q. -- how many -- are you able to break them down, 11 acute versus chronic, or did I already ask you 12 that? I may have, but I don't remember the answer. 13 A. The majority were acute. 14 Q. A majority is a funny term though. It means 15 anything more than 50 percent. Can you break it 16 down any -- you may not be able to. 17 A. I may not be able to. 18 Q. That's fine, but if you can, I'd like you to break 19 it down further. 20 A. I can't give you an exact number. Most -- 21 MS. REINKER: If you can't give a 22 number, that's your answer. 23 Q. So the best you can say is that probably a 24 majority -- 25 A. Yes. 18 1 Q. -- of the cases you've seen are acute as opposed to 2 chronic? 3 A. Yes. 4 Q. Of those cases that you've seen, these are all 5 patients that you've actually had an opportunity to 6 diagnose and/or treat? 7 A. Yes. 8 Q. Are there any other such cases you're aware of where 9 they were either in the system on the way to see you 10 but didn't make it because before they got to you 11 they succumbed? 12 A. It has happened, yes. 13 Q. More than once? 14 A. Probably. 15 Q. Can you tell me how often? 16 A. I can't give you an exact number, no. 17 Q. Can you give me an estimate as to how often that has 18 occurred, obviously that you're aware of? 19 A. I can't give you an exact number. I mean, I know 20 it's happened. It's not a frequent occurrence. 21 Q. Okay. Somewhere between, what, one and four times, 22 would you say? 23 MS. REINKER: Don't guess, Doctor. If 24 you don't know, you don't know. 25 A. I really don't know exactly. I know that it's 19 1 happened. 2 Q. So we'll talk about the ones that you've had contact 3 with. Those have typically come to you by way of a 4 referral of one sort or another? 5 A. Yes. 6 Q. And how many of those have you been able to 7 successfully treat? 8 A. I'd say -- I don't have exact mortality statistics 9 for my own experience, but I would estimate probably 10 80 percent of them. 11 Q. Do you know Dr. Haluska? 12 A. No, I don't. 13 Q. Have you ever been represented by Ms. Reinker 14 before? 15 A. No. 16 Q. Or this firm? 17 A. No. 18 Q. Who's your -- well, have you ever been involved as a 19 medical witness in a malpractice case before? 20 A. Do you mean as an expert? 21 Q. As an expert. 22 A. No. 23 Q. As a defendant? 24 A. Yes. 25 Q. Can you tell me how many times? 20 1 MS. REINKER: Objection to this whole 2 line, but go ahead. 3 A. I was deposed once. 4 Q. Who represented you in that case? 5 A. That was Bill Meadows. 6 Q. Do you happen to remember who sued you or would you 7 rather forget that? 8 A. The suit was by the Estate of Jean Siegel. 9 Q. The Estate of Jean Siegel? 10 A. Yes. 11 Q. Aside from the practice of medicine, actually seeing 12 patients and treating them, what else does your 13 practice entail in terms of administrative duties or 14 any -- 15 A. I'm a clinician. 16 Q. Are there certain texts that you tend to rely on 17 from time to time in particular as it relates to 18 issues that might come up regarding, let's say, 19 aortic dissection, for example, random example? 20 A. I use a wide variety of texts. 21 Q. Can you give me some idea as to what's in your 22 library that you might rely on for these types of 23 issues? 24 A. I use standard journals, Journal of Thoracic and 25 Cardiovascular Surgery, Annals of Cardiothoracic 21 1 Surgery. 2 Q. What was the first one, Journal of -- 3 A. Thoracic and Cardiovascular Surgery. And then the 4 standard cardiothoracic surgical texts. I'm trying 5 to remember the authors. 6 Q. Glenn? 7 A. Very rarely I've used Glenn. 8 Q. Can you think of any others? 9 A. I mean, a large number of them, none that, you know, 10 I zero in on. 11 Q. Okay. Do you ever look at any cardiology texts as 12 part of your armamentarium of literature? 13 A. No, not -- no. 14 Q. Give me some idea as to what your experience is with 15 emergency medicine. Have you ever been an emergency 16 physician either by moonlighting or otherwise? 17 A. I've rotated through the emergency room as a 18 resident as part of the residency training. 19 Q. For how long were you an emergency room rotator? 20 A. I would say over a five-year period, maybe -- or, 21 well, seven-year residency, actually, maybe six 22 months total over that period of time. 23 Q. So those were six circumstances, presumably, where 24 you were working in close conjunction with somebody 25 who was a board certified emergency physician? 22 1 A. Yes. 2 Q. So beyond that six months, have you had any other 3 emergency medicine experiences? 4 A. No. 5 Q. Do you consider yourself an expert in emergency 6 medicine? 7 A. No. 8 Q. Do you consider yourself an expert in -- have you 9 ever worked in a CDU? 10 A. No. 11 Q. Have you ever -- well, are there CDUs in any of the 12 institutions where you have or are practicing? 13 A. I believe there was a similar unit at University of 14 Michigan. 15 Q. University of Michigan. Let me see here. So when 16 you were doing your residency in thoracic surgery, 17 did you have occasion to interface with that unit 18 from time to time or no? 19 A. I don't think I actually ever went in there. 20 Q. Do you feel you're in a position to render opinions 21 regarding the standard of care as it relates to 22 emergency physicians and internists working in a 23 CDU? 24 A. As it relates to aortic dissection, yes. 25 Q. And tell me how it is that you feel that you can do 23 1 that. 2 A. The aortic dissections frequently present through an 3 emergency room, and I'm frequently consulted to see 4 them in an emergency room. 5 Q. So by virtue of the fact that you, as a 6 cardiothoracic surgeon, have to interface with 7 patients who go through emergency rooms in order to 8 either be worked up or diagnosed, and you have to 9 interface with those physicians who work there as 10 well, you feel that that gives you the appropriate 11 expertise to render opinions as it relates to the 12 standard of care in this case as it pertains to 13 aortic dissection and its diagnosis? 14 A. Yes. 15 Q. All right. And that would be true of any thoracic 16 surgeon, presumably, who interfaces in that fashion 17 with folks in emergency rooms with that diagnosis? 18 A. Well, it would be up to the individual. 19 Q. Right, but there's nothing unique about you that 20 makes you competent to do that whereas other 21 thoracic surgeons wouldn't necessarily be? 22 A. Not necessarily, although I do know cardiothoracic 23 surgeons who don't like to deal with aortic work. 24 Q. But to the extent cardiothoracic surgeons deal with 25 aortic work and deal with it as it flows in their 24 1 direction from an emergency room, they're as 2 equipped as you are to deal with these standard of 3 care issues? 4 A. I would say in general. 5 Q. And the same would be true of cardiologists to the 6 extent that they get involved in these situations? 7 MS. REINKER: Objection. 8 A. I would disagree with that. 9 Q. All right. And why is that? 10 A. To me an aortic dissection is a cardiac surgical 11 problem. Cardiologists are maybe -- may be involved 12 but maybe incidentally in the diagnosis and 13 treatment. 14 Q. I guess where I'm coming from is this. Certainly 15 emergency room physicians or physicians who work in 16 emergency rooms and deal with this entity would be 17 in a position to opine about the standard of care? 18 A. Yes. 19 Q. Have you had a chance to look at your report before 20 this deposition? 21 A. Yes. 22 Q. We're going to talk about it briefly, if we could. 23 MS. REINKER: Why don't you get it out, 24 Doctor. 25 Q. I had a copy that I marked up and I've proceeded to 25 1 lose it. That's all right. I don't really need 2 it. 3 Take a look at paragraph -- well, maybe we 4 should do it this way. You say in your report that 5 the chest pressure that Mrs. Broncaccio had in the 6 emergency room was relieved by Mylanta. Do you 7 recall saying that in your report? I'll refer you 8 to paragraph three, I believe, on page one. 9 A. I know it's there, I just -- oh, yes, here we go. 10 Q. Do you see it? 11 A. Yes, Mrs. Broncaccio attributed her chest pressure 12 to ingestion of coffee, and at one point Mylanta 13 relieved it. 14 Q. What's the significance of that to you? 15 A. The significance of that is that an antacid is 16 unlikely to give relief of pain associated with 17 severe conditions such as myocardial infarction, 18 angina, dissection. 19 Q. So by virtue of the fact that, as you've indicated, 20 Mylanta relieved the pain, you would tend to move 21 the diagnosis of aortic dissection down in the 22 differential rather than up? 23 A. Yes. 24 Q. All right. Can we agree that any differential 25 diagnosis of a patient presenting with chest pain in 26 1 an emergency room setting has to include, in 2 addition to MI and coronary ischemic events, 3 dissection of the aorta as well? 4 A. Not every presentation of chest pain, no. 5 Q. Well, in this case, would this presentation of 6 Frances Broncaccio have included the differential 7 diagnosis -- in the differential diagnosis aortic 8 dissection? 9 A. At this point it would have been very low on the 10 list, if at all. 11 Q. So you wouldn't have placed it on the list at all at 12 any time or simply at the time of presentation? 13 A. I would not have put it on the list of diagnoses. 14 Q. Ever during this stay? 15 A. Not significantly, no. 16 Q. Well, so if Dr. Haluska says he placed it on his 17 differential list, it's your contention that he's 18 doing something that wasn't even necessary, given 19 the presentation? 20 A. I believe that the likelihood, based on her 21 presentation, was low. 22 Q. All right. 23 A. He may have placed it on his differential, but it 24 would have been very low. 25 Q. Okay. So the differential diagnosis could have 27 1 included it, but it would have been low on the list; 2 fair statement? 3 A. It could have. 4 Q. Yeah. And if it was on the list and Mylanta was 5 capable of relieving the symptoms, it would get even 6 lower? 7 A. Yes. 8 Q. And if Mylanta was not capable of relieving the 9 pain, it would not get any lower? Let's put it this 10 way, if Mylanta was unable to relieve the pain, you 11 would not be able to exclude significant ischemic 12 diseases, for instance, as a cause of the pain, 13 correct? 14 A. It would have been -- the fact that Mylanta relieved 15 her pain would lead me to believe that she had -- 16 Q. A digestive problem? 17 A. -- a digestive problem. If it had not, I don't 18 believe it would have changed things significantly. 19 Q. All right. Where is it that you -- where is it in 20 the records or materials that you reviewed that you 21 learned that her chest discomfort was relieved with 22 Mylanta? 23 A. I'd have to look at the record. 24 Q. If you would, I would like to see if we can look at 25 that, please. I'll give you a hint. 28 1 A. Okay. 2 Q. Just so we don't waste a lot of time, and if I'm 3 wrong, you tell me. 4 A. Okay. 5 MS. REINKER: Can I give him a hint? 6 MR. HIRSHMAN: If you want to, you can, 7 too, Susan. 8 Q. I would suggest you may have learned it from the 9 dictation of Dr. Haluska, the first narrative 10 paragraph, last line. 11 A. Yes. 12 MS. REINKER: That's not what my hint 13 was going to be. 14 A. There may be other areas, but it certainly is 15 there. 16 Q. Do you see it anywhere else or did you see it 17 anywhere else in these records? 18 MR. HIRSHMAN: Susan, feel free to help 19 him. 20 MS. REINKER: Okay. Referring to the 21 dose given at 12:30 at night, I think, right? 22 MR. HIRSHMAN: It's 12:30 in the 23 morning. 24 MS. REINKER: Right, a.m. 25 MR. HIRSHMAN: I don't think that's 29 1 from that night. 2 MS. REINKER: That's different. 3 A. So there are two areas. 4 Q. Where is the second one? 5 A. The second one is on the nursing document, 6 continuation nursing documentation. I don't have a 7 page number of any kind for you. 8 Q. I've got it here somewhere too, so I'll be with you 9 in a minute. I'm lagging behind you. Oh, I see 10 where you are. Okay. Where are you? 11 A. Let's see. She described pressure as four out of 12 ten at 1:00. 13 Q. We're looking for Mylanta, right? 14 MS. REINKER: Well, she was given 15 Mylanta -- 16 A. She was given it. 17 MS. REINKER: -- just before that. 18 A. Yeah, and then her discomfort is listed as two out 19 of ten after. 20 Q. She was given Mylanta when? 21 A. I have to look at the medication record. At 12:30. 22 Q. And you are concluding that from reviewing the 23 medication record, nursing; is that right? 24 A. Yes, I believe so. 25 Q. Let me see what you're looking at. 30 1 A. You just lost it. Medication record, nursing, CDU. 2 Q. And it's a document that has at the top some bar 3 codes? 4 A. Yes. 5 Q. And then it says as a number of items under 6 medication, the first one being pulse ox. X four? 7 A. Yes. 8 Q. And then there's the next line down is a slash? 9 A. Right. 10 Q. And the next one is coated aspirin? 11 A. Yes. 12 Q. 325 milligrams? 13 A. Yes. 14 Q. And the very last entry on the page is Mylanta 30 15 cc's Q four hours PRN? 16 A. Yes. 17 Q. And you're telling us that that says that it was 18 given at 12:30? 19 A. Yes. It's recorded as being 12:30. 20 Q. And 12:30 in the morning in the emergency room, 21 correct? 22 A. Yes. 23 Q. All right. And to you that is evidence that the 24 Mylanta reduced the pain, the fact that it was given 25 at 12:30 and at 1:00 we have chest pain that is 31 1 reducing from a level of four to a level of two? 2 A. Chest pressure. 3 Q. Chest pressure. 4 A. And a note by Dr. Haluska timed, I think, at 2:00 5 a.m. that also indicated that he felt she had 6 received relief with Mylanta. 7 Q. All right. You also mention in your report that 8 patients with acute aortic dissection often appear 9 restless? 10 A. They can. 11 Q. What makes them present in that fashion? 12 A. It's hard to ascribe a particular cause, but it's 13 usually hemodynamic instability and poor perfusion. 14 Q. How does that -- I guess I'm asking you to describe 15 as best you can the mechanism or pathway by which 16 the dissection translates itself into restlessness. 17 A. Well, I think it's multifactorial, it's a 18 combination of pain, poor perfusion, for example of 19 a limb or of an organ system. It would be hard 20 to -- I couldn't ascribe the exact cause, but in my 21 mind those are the contributing factors. 22 Q. And you have seen that association between aortic 23 dissection and restlessness in the patients that 24 you've treated? 25 A. I have. 32 1 Q. You also mention poor perfusion, I believe, in your 2 report? 3 A. Yes. 4 Q. Same paragraph. 5 A. Uh-huh. 6 Q. What is poor perfusion? 7 A. Well, it's a lack of blood flow, lack of adequate 8 blood flow. 9 Q. So poor perfusion can manifest itself by, I guess, a 10 direct documentation of that poor blood flow, for 11 instance, by Doppler studies, that's one way? 12 A. Yes. 13 Q. And I guess there's more indirect ways to do or more 14 clinical ways and less scientific or fancy ways, 15 such as feeling a limb? 16 A. You can take a pulse, feel a limb, feel the skin. 17 Q. Skin -- 18 A. Check the tactile temperature. 19 Q. So a poorly perfused limb would be a cold limb? 20 A. Yes. 21 Q. And a poorly perfused limb might have a pulse but 22 might have a lesser pulse? 23 A. Yes. 24 Q. So in order to determine whether a limb is 25 properly -- is poorly perfused or not, you'd need to 33 1 compare it to another limb? 2 A. As -- you wouldn't have to, but it's helpful. 3 Q. I guess what I'm getting at is this. A poorly 4 perfused limb might still have a pulse? 5 A. Yes. 6 Q. All right. And to determine whether it's poorly 7 perfused or not, you'd need to make a qualitative or 8 quantitative assessment as to just how significant 9 and vigorous that pulse is? 10 A. It would not just be the pulse, it would be the 11 appearance and the feel. 12 Q. So it would be the pulse, the temperature? 13 A. Temperature, the feel and the look of the skin, the 14 patient's own assessment of how that limb feels. 15 Q. Whether it feels -- 16 A. It's multifactorial. 17 Q. Okay. You also mention, I think, cerebral 18 malperfusion at one point in your report -- 19 A. Uh-huh. 20 Q. -- as being something that is often associated with 21 dissection; is that right? 22 A. Yes. 23 Q. Now, Mrs. Broncaccio had a syncopal episode, didn't 24 she; are you aware of that? 25 A. That's not certain to me. 34 1 Q. It's been described in the records by various people 2 as a syncopal episode, I believe, though? 3 A. Some have. 4 Q. So let's talk about syncope for a moment. One of 5 the possible sources of syncope could be a reduction 6 in perfusion to the brain, could it not? 7 A. It can be. 8 Q. And in fact, you've had an opportunity, I presume, 9 to not only look at the records here, I presume 10 you've looked at the autopsy as well? 11 A. Yes, I have. 12 Q. Did you see anything in the autopsy that would 13 suggest that the brain of Frances Broncaccio was 14 deprived of oxygen and blood at some point? 15 A. May I look at the autopsy report? 16 Q. Sure. I'll just, to speed this up, refer you to 17 the -- 18 A. I think you're referring to page two. 19 Q. Page two. There's a reference on page two, is there 20 not, to a dissection that extended into the right 21 common carotid artery? 22 A. Yes. 23 Q. Do you see that? You would agree that such an 24 extension of a dissection into the right common 25 carotid artery could cause signs and symptoms 35 1 consistent with a syncopal episode? 2 A. It could. 3 Q. Do you have an opinion as to whether they did in 4 this case? 5 A. It's not known. 6 Q. It's not known, you don't know one way or the 7 other? 8 A. We don't know if the episode, which was described at 9 her home, was caused by this finding on the 10 autopsy. 11 Q. Certainly, that finding on the autopsy is one 12 reasonable explanation for the syncopal episode? 13 A. We don't know if that was the cause of this episode 14 that she had at home or that that was truly 15 syncope. 16 Q. All right. But it's certainly one explanation that 17 would be a reasonable one, I'm not saying it's the 18 only one, but you'd agree that's a reasonable 19 explanation for the syncopal -- or for the 20 neurologic event that occurred at home, whether you 21 call it surgery or something else? 22 MS. REINKER: Objection. It's been 23 asked and answered. I think he said we don't 24 know. 25 A. To my mind the event at home, which was described as 36 1 inability to speak, with the patient retaining her 2 eyes open and the ability to hear and it was 3 associated with documented bradycardia, the first 4 thing that would come to mind is a vasovagal event, 5 and it's not consistent with syncope that I have 6 seen. 7 Q. We're sitting here with this autopsy in front of us 8 now and what you're telling me is that even with 9 this autopsy in front of you, you don't believe that 10 that event at home was the result of what you see on 11 the autopsy as it relates to the carotid artery? 12 A. I'm saying we don't know that that was what caused 13 the event at home. 14 Q. All right. So all I'm asking is that's one possible 15 cause, correct? 16 MS. REINKER: Objection. He's 17 repeatedly said he doesn't know. 18 MR. HIRSHMAN: No, Susan, why don't you 19 just let us have a discussion here. 20 Q. Let's do this then, give me your list of possible 21 causes for that event at home. 22 A. It could have been a vasovagal event. 23 Q. That's one. 24 A. Which is nonspecific. She could have had a TIA. 25 Q. Two. 37 1 A. She could have had an absentia seizure. 2 Q. Three. 3 A. She could have had a stroke, I suppose. 4 Q. Four. 5 A. And it could be explained by dissection. 6 Q. Of the carotid artery? 7 A. Could be. 8 Q. Got it, five. Let's go through that list again. 9 MR. HIRSHMAN: Why don't you read that 10 list back to me. 11 MR. RUF: Here. 12 Q. Did you see any evidence on autopsy of a stroke? 13 A. I'll have to look. I don't recall seeing any. It 14 lists no pathologic diagnosis on the microscopic 15 description of the brain. It says no gross 16 abnormalities. 17 Q. So you see nothing in the autopsy that suggests the 18 existence of a stroke? 19 A. Correct. 20 Q. Did you see anywhere any suggestion that Frances 21 Broncaccio had seizures by history? 22 A. No. 23 Q. Any suggestion anywhere that she had ever had a TIA 24 historically? 25 A. Not that I'm aware of. 38 1 Q. All right. Or that she ever had vasovagal events in 2 the past? 3 A. No, although most people have at some point in their 4 life had a vasovagal event. 5 Q. In the cases that you've seen of dissection, the 12 6 to 20 that we talked about, how many of them were 7 type one or Type III dissections, Type III being one 8 that starts in the descending and proceeds downward 9 from the starting point? 10 A. Right. I can't tell you exactly. I've seen 11 probably an equal mix of ascending and descending, 12 to break down those broad categories, ascending and 13 descending dissections. 14 Q. Have you seen patients in that group of 12 to 20 15 that you've seen that have had, in addition to the 16 chest pain that we have already talked about, back 17 pain? 18 A. Yes. 19 Q. Tell me, if you would, how back pain manifests 20 itself, what causes back pain to occur in patients 21 with a dissecting aneurysm of the -- a dissection of 22 the aorta? 23 A. It's the result of tearing of the aortic layers in 24 the aorta along the spine. 25 Q. So when -- if you're talking about a Type I 39 1 dissection which starts near the aortic root -- 2 A. Right. 3 Q. -- that typically manifests itself as pain in the 4 chest? 5 A. Chest. 6 Q. And then as it goes up the arch and down into the 7 descending aorta it begins to manifest itself as 8 back pain? 9 A. It can. 10 Q. About how many -- how frequently have you -- how 11 frequently have the patients that you've seen with 12 dissections into the descending aorta presented with 13 back pain? 14 A. I can't give you an exact percentage, but it's very 15 common. 16 Q. So it's a signal that needs to be taken seriously? 17 A. If it's of the appropriate nature, yes. 18 Q. So patients with chest pain who subsequently present 19 with back pain are presenting in a way that should 20 give rise to at least a suspicion of dissection? 21 A. Not in every case. 22 Q. Well, obviously if somebody presents with what we 23 know to be a back pain from another source, you 24 wouldn't take it as seriously, is that what you're 25 saying? 40 1 A. It would depend on the nature, the time course, you 2 know, the full description of both the back and the 3 chest pain. 4 Q. Tell me, if you would, what the prototypical nature 5 and time course is that you would expect in a 6 patient presenting with chest pain followed by back 7 pain brought on by aortic dissection. 8 A. Well, it's very typically very precipitous, sudden 9 onset, high degree of severity, classically 10 described as tearing or ripping, if it's limited or 11 it begins in the ascending aorta it may start in the 12 chest. If it does -- if and when it does progress 13 to the descending aorta it may radiate into the back 14 in the intra-scapular region and again is typically 15 fairly severe and a tearing or ripping nature or 16 described as such. 17 Q. And as it proceeds down the back, as the dissection 18 proceeds downward with further delamination 19 associated with elevations in blood pressure or the 20 pumping mechanism of the heart, the pain will move 21 downward? 22 A. It can. 23 Q. And if there is that kind of migration, that's 24 certainly something that would tend to suggest a 25 pathological entity such as a dissection? 41 1 A. If the pain is appropriate, yes. 2 Q. Would you agree, I think we can all agree, that 3 dissection is certainly less common than myocardial 4 infarction? 5 A. Yes. 6 Q. And it's less common than unstable angina? 7 A. Yes. 8 Q. But it's common enough so that in your short career 9 you've seen 12 to 20 of these cases? 10 A. Yes, but at times it's centers, major refer centers 11 for dissection. 12 Q. You would agree that it's the most common 13 catastrophic condition of the aorta? 14 A. It is, although -- 15 Q. It presents itself? 16 A. -- it's, all told, relatively rare. 17 Q. Relatively rare as compared with ischemia, but 18 certainly frequent enough so that it needs to be at 19 least considered as something that should be placed 20 on a differential diagnosis in a patient who 21 presents to an emergency room with chest pain and 22 back pain and syncope? 23 A. If the particulars of those symptoms were 24 appropriate, yes. 25 Q. And it becomes more likely to make its way on to 42 1 that list of differential diagnoses as other causes 2 of pain get excluded; fair statement? 3 A. Again, it would depend on the particulars of those 4 symptoms. 5 Q. And as we begin to rule out cardiac ischemia as a 6 cause of the pain, dissection would certainly have 7 to be taken more seriously as well? 8 A. Are you talking about in general or in this case? 9 Q. In general, in general. 10 A. If you were -- again, it would depend on more detail 11 about the type of pain we were talking about -- 12 Q. Assuming the pain -- 13 A. -- and the other details of the case. 14 Q. But assuming the pain was of sufficient character in 15 your mind, certainly the fact that the EKGs start 16 coming back negative and the enzymes start coming 17 back negative, those facts would have to force you, 18 as a clinician, to look elsewhere for a cause? 19 A. If you're -- you would have to consider other 20 diagnoses, but that does not mean that the aortic 21 dissection necessarily is your next diagnosis. 22 Q. I'm not -- 23 A. That depends on the type of pain and the overall 24 clinical picture. 25 Q. All right. You would agree with this much, the 43 1 things that you've got to rule out most quickly are 2 those that are most potentially life threatening? 3 A. Yes. 4 Q. And when it comes to chest discomfort in an 5 emergency room setting, what are the most life 6 threatening conditions that need to be ruled out in 7 the presence of chest pain or discomfort? 8 A. Well, again, it depends on the details of the 9 presentation. If you have someone with the 10 appropriate clinical scenario, then you would have 11 to rule out -- you rule out the most life 12 threatening things. If -- 13 Q. What would those be? 14 A. Again, it depends on how they present. 15 Q. You seem, for one reason or another, and let's just 16 deal with it straightforwardly here, you're 17 unwilling to say that dissection even appears on the 18 list, should even appear on the list in this case of 19 differential diagnoses for some reason, and I'm 20 going to ask you why. Tell me exactly why it is 21 that dissection does not -- that you would not have 22 put dissection on your differential diagnosis. 23 A. When she presented, and from every indication I have 24 on the chart, she had very low level chest 25 discomfort that was intermittent in nature and was 44 1 associated with a variety of other complaints which 2 were fairly nonspecific. She had some nausea, she 3 had a headache. She had -- and then in addition to 4 that, other laboratory evaluations, which were, you 5 know, that the whole clinical picture to me was 6 fairly benign. 7 Q. What were those laboratory evaluations? 8 A. She had a normal, essentially normal, CBC and 9 chemistries. Her chest x-ray was not suggestive, 10 her physical examination was not suggestive. 11 Q. Which physical examination was that? 12 A. That performed by Dr. Haluska and the subsequent 13 exams by the nurses of her pulses, et cetera. 14 Q. What evidence do you have of the -- well, we'll get 15 to that in a minute. Anything else that persuades 16 you that Mrs. Broncaccio didn't deserve to have the 17 diagnosis of aortic dissection included in her 18 differential diagnosis? 19 A. Just as I said, her presentation. 20 Q. Right, and the things that we mentioned. And I'll 21 go over them and give you an opportunity to add any 22 you want or subtract any that you want to subtract. 23 Low level of chest discomfort was one. The 24 intermittent nature of the discomfort, the next one 25 was I have an N here and I don't know what the N 45 1 stands for. 2 A. I think she had complained of some nausea. 3 Q. Nausea, that's what it stands for? 4 A. She had headaches. 5 Q. Nausea, headaches, normal CBC, chemistries that were 6 nonindicative, chest x-ray that was nonindicative, 7 physical examination that was not indicative? 8 A. Her general appearance was described as being in no 9 distress. 10 Q. And the nurse's findings were nonindicative? 11 A. Right. 12 Q. So based on all that, you wouldn't have placed 13 aortic dissection on the differential diagnosis? 14 A. Not at that time. 15 Q. At any time would you have? 16 A. Well, certainly when she -- her -- at the time of 17 her arrest, it would have been. 18 Q. How about prior to that? 19 A. No, I think it would have actually been -- if it had 20 been, it would have been a little lower, because of 21 her complaints of -- she was having diarrhea, she 22 was having nausea, she described some chills, sort 23 of what looked like to me sort of vague 24 constitutional symptoms. 25 Q. Are you aware of any statistics as to the percentage 46 1 of time that nausea and/or vomiting are found to 2 exist in association with aortic dissection? 3 A. I don't have any statistics, no. 4 Q. Do you have any experience in that regard? 5 A. In my experience it's not a prominent part of the 6 presentation. 7 Q. Does that mean it doesn't exist in association or 8 simply that there are other -- what do you mean by 9 not prominent? 10 A. It doesn't come to my mind as a factor in deciding 11 if someone has a dissection or not. 12 Q. What is it about the -- about intermittent chest 13 discomfort that persuades you that that 14 particular -- is that a symptom or a sign? That's a 15 symptom? 16 A. It would be a symptom. 17 Q. Is inconsistent with dissection? 18 A. Well, it would, in my experience, the discomfort is 19 pretty intense and it tends to persist. 20 Q. Okay. What do you learn from a CBC that relates to 21 the presence or absence of dissection? 22 A. If -- very often the hematocrit will drop because of 23 some leaking from the dissection. 24 Q. Is that the main -- 25 A. That, and they may have an elevation of the white 47 1 count due to demargination from the inflammation 2 associated with the tear and the dissection. 3 Q. What is it in the chemistries you would be focused 4 on? 5 A. She had a normal creatinine, no evidence of renal 6 dysfunction. 7 Q. Well, you wouldn't expect the creatinine to be 8 abnormal prior to the dissection reaching the renal 9 arteries, would you? 10 A. That's true. 11 Q. So a normal creatinine -- creatinine is relevant to 12 this whole analysis to the extent that a dissection 13 extends far enough to disrupt the blood supply to a 14 particular end organ, this one being the kidneys? 15 A. Yeah, although if she had become hypotensive or had 16 a low cardiac output on the basis of her dissection, 17 even if it hadn't reached the kidneys, you could 18 begin to see elevations of BUN and creatinine and a 19 decrease in urine output. 20 Q. So by either of those mechanisms you would be 21 suspicious of an elevated creatinine? 22 A. It could be part of the picture, yes. 23 Q. By the same token, a headache could be a cause of a 24 loss of supply of blood to the brain, could it not? 25 A. I'm not aware of that association. 48 1 Q. What percentage of chest x-rays -- what percentage 2 of initial chest x-rays in people presenting with 3 aortic dissection are normal? 4 A. In my experience, very few of them are totally 5 normal. 6 Q. Have you seen any literature on this subject? 7 A. Not recently, no. 8 Q. If I told you that there are studies out there that 9 suggest as high as 55 percent of them are normal, 10 would that surprise you? 11 A. Yes, it would. 12 Q. What is it about Dr. Haluska's physical examination 13 that you find most supportive of the absence of a 14 dissection? 15 A. Let me just take a look at it. 16 Q. And just so that we understand what it is you're 17 looking at, you're looking at a physical examination 18 that was written out on December 22nd? 19 A. Yes. 20 Q. Two weeks after the events that were being 21 documented, correct? 22 A. Correct. 23 Q. Let me find mine. All right. 24 A. To me the most important part of it is that she was 25 in no apparent distress. 49 1 Q. Anything else? 2 A. She had really a very soft murmur, her abdomen was 3 benign, her pulses were described as normal, she had 4 no neurologic deficits, but the main thing to me is 5 the overall assessment of a patient who was in no 6 distress. 7 Q. What do you see in terms of pulses? It says normal 8 pulses? 9 A. Normal pulses. 10 Q. Do you know what pulses were taken? 11 A. No, I don't. 12 Q. What limbs? 13 A. No. 14 Q. Is there anything in this physical examination that 15 you find supportive of the diagnosis of dissection? 16 A. No. 17 Q. Nothing? 18 A. No. 19 Q. Does this appear to you to be a thorough physical 20 examination? 21 A. To me it's very typical of the physical exams which 22 are done in an emergency room. 23 Q. Is this a detailed physical examination? 24 A. You can make a physical exam, you know, very 25 detailed, but it's, as I said, I think it's very 50 1 typical of an emergency room, of a standard physical 2 exam done in an emergency room. 3 Q. What's today's date? Today is the 9th. I want you 4 to think back to the last week of February. 5 A. Okay. 6 Q. And I don't want to know the name of the patient. 7 Did you do any physical examinations on patients 8 that week? 9 MS. REINKER: Who subsequently died? 10 A. I did many. 11 Q. I want you to pick out one of them and tell me 12 exactly what that exam was. Can you do that? 13 MS. REINKER: Objection. 14 A. I would agree I don't have an event that stands out 15 in my mind that would lead me to tuck that away. 16 Q. All right. It's fair to say that physicians who see 17 lots of patients -- one of the reasons we do -- we 18 make records is because physicians tend to be busy 19 and they see lots of patients; fair statement? 20 A. Yes. 21 Q. And the way that you keep the facts pertaining to a 22 particular patient straight is by writing down what 23 you saw and what you observed near the time that you 24 saw and observed it? 25 A. Yes. 51 1 Q. And the danger is that if you wait any period of 2 time that you're going to not only forget what it is 3 you saw but you're going to start mixing it up with 4 other patients that you saw; fair statement? 5 A. It can happen. 6 Q. Are you aware of any other physical examination 7 documented in the records, other than this one 8 physical examination that was done, purports to have 9 been done, on December 7th and to have been 10 documented on the 22nd? 11 A. Well, there are nursing assessments which include 12 parts of a physical examination. 13 Q. Are you aware of any other physical examination done 14 by a physician that's in the chart in this case 15 relating to Frances Broncaccio? 16 A. Let me just take one quick look. I don't recall off 17 the top of my head. She was examined at the time of 18 her arrest, 13:14. 19 Q. By Dr. Ryder? 20 A. I believe that's his signature. 21 Q. All right. Other than that, are you aware of any 22 others? 23 A. No. 24 Q. Would you agree with me that a physician who's 25 engaged in a workup of a patient for chest pain or 52 1 discomfort doesn't necessarily have to rule out the 2 top diagnosis on his differential diagnosis before 3 embarking on an endeavor to rule out other diagnoses 4 on his differential diagnosis? 5 A. Yes. 6 Q. You can certainly and in many instances should be 7 working on more than one track at a time? 8 A. You may. You don't necessarily have to. 9 Q. Well, the more serious -- on a continuum, the more 10 serious and life threatening the diagnoses are below 11 the initial diagnosis, the more reasonable it is to 12 be working on more than one diagnosis at a time? 13 A. Depending on the patient's presentation and status. 14 Q. I guess what I'm getting at is there's nothing that 15 says you have to rule out Diagnosis A before you 16 move on to Diagnosis B? 17 A. No, but a patient who is in extremis is going -- 18 you're going to be working on multiple things much 19 more rapidly than someone who is not. 20 Q. Wouldn't you agree that in some instances it 21 certainly is in the best interest of the patient to 22 rule out -- to be working on multiple tracks of 23 diagnoses at a particular time? 24 A. In some patients, yes. 25 Q. And in this case, had that been done for Frances 53 1 Broncaccio and if one of those differential 2 diagnoses had been aortic dissection, a very simple 3 test could have been done to diagnosis it? 4 A. I think that's very theoretical. 5 Q. Well, it's this theoretical, if a CT scan had been 6 done there's little doubt that it would have made 7 the diagnosis; fair statement? 8 A. It depends on when it would have been done. 9 Q. If a CT scan had been done at any time during the 10 emergency room admission and CDU admission of 11 Frances Broncaccio, chances are it would have 12 diagnosed a dissection? 13 A. We don't know exactly when she dissected. 14 MS. REINKER: But there's no note. 15 Q. Are you suggesting she presented to the emergency 16 room with a problem independent of her dissection? 17 A. It's possible. 18 Q. Are you suggesting that to a reasonable probability 19 she presented to the emergency room with a 20 coincidental condition that had nothing to do with 21 her dissection? 22 A. It's possible. 23 Q. Okay. 24 A. It's possible. 25 Q. It's not likely? 54 1 A. I don't have any -- I mean, like I said, it's 2 possible that she had something else going on. We 3 don't know, you know, at any point if a CT would 4 have picked up a dissection. 5 Q. And let's put it this way, if she presented to the 6 emergency room with a dissection -- 7 A. If she presented with a dissection -- 8 Q. -- chances are that a CT would have picked it up? 9 A. It could have, although there are issues of 10 sensitivity and specificity. 11 Q. That was going to be my next question, the 12 sensitivity of a CT scan for a dissection is 13 somewhere in the neighborhood of 99 percent, isn't 14 it? 15 A. I don't know that. 16 Q. Do you dispute that? 17 A. No, it's just I don't know that. 18 Q. Dissections don't always balloon out, do they? 19 A. I don't know what you mean. 20 Q. Well, when you talk about an aortic aneurysm, you 21 talk about an out pouching, it's a ballooning out? 22 A. Yes. 23 Q. In contradistinction to that, a dissection is where 24 the different layers of the actual aorta delaminate? 25 A. Correct. 55 1 Q. Sometimes they delaminate in a fashion where the 2 outer layers push out and push against other 3 structures in the chest? 4 A. Correct. 5 Q. Sometimes the laminate is in a fashion where the 6 inner layers are pushed in causing a false lumen 7 with the outer layer of the aorta remaining pretty 8 much at the same diameter it was to begin with? 9 A. Well, there's always a false lumen by definition. 10 Q. Correct. 11 A. And they are not always associated with aneurysm, 12 that's true. In my experience, they almost always 13 are associated with some adventitial hematoma. The 14 aorta, whenever you operate on one, for example, you 15 never see a normal appearing aorta when you go in. 16 Q. But sometimes you find an aorta that -- what's the 17 outer layer of the aorta called? 18 A. The adventitial layer. 19 Q. Sometimes you find the adventitial layer having been 20 stretched out and larger in diameter, sometimes you 21 find that it's not; fair statement? 22 A. No, in my experience there's almost always either 23 hematoma or edema. I mean, the outer layer in the 24 area of dissection almost never -- I have never seen 25 it look normal. 56 1 Q. Have you ever seen it look normal in diameter? 2 A. Well, I would have to say no. In my experience 3 there is, you know, almost always -- I mean, when I 4 think of dissection, when I open a chest, what I see 5 is a, you know, very red and inflamed structure, but 6 it's not always aneurysmal. 7 Q. When you say aneurysmal, you mean it isn't always 8 displacing a greater volume? 9 A. No, by aneurysmal I mean an actual true dilatation 10 of the entire -- of the true aorta. 11 Q. All right. So sometimes you see a dilatation of the 12 aorta, sometimes you don't; is that what you're 13 telling me? 14 A. No. I'm saying that, one, as you know, aortic 15 dissection is not always associated with an 16 aneurysm, and you're asking me about whether or not 17 the aorta can stay of normal caliber. 18 Q. I guess that's what we're talking about. 19 A. Yeah, in my experience I would say, no, it's not of 20 normal caliber because there is blood and, you know, 21 edema formation that works its way into the 22 adventitia. 23 Q. All right. 24 A. So when I open a chest, I have never seen one look 25 normal. 57 1 Q. You've never seen one look normal in terms of size? 2 A. That's part -- I would say that's part of the 3 overall picture, yeah, that you're looking at a sort 4 of swollen mass of inflamed aorta. 5 MS. REINKER: Off the record. 6 - - - - 7 (Thereupon, a discussion was had off 8 the record.) 9 - - - - 10 Q. You see patients with evolving MIs? 11 A. Yes. 12 Q. With some frequency, I imagine? 13 A. Uh-huh, yes. 14 Q. You see patients with unstable angina? 15 A. Yes. 16 Q. With some frequency as well? 17 A. Yes. 18 Q. And that's part of what you do, is intervene in 19 situations to revascularize patients in order to 20 avoid the destruction of heart tissue under those 21 circumstances? 22 A. Yes. 23 Q. And it's fair to say that patients who present with 24 cardiac ischemia often present with chest discomfort 25 that is sometimes pain and sometimes described in 58 1 other terms? 2 A. Yes. 3 Q. Pressure is a significant event and is, in essence, 4 equivalent to pain in that clinical situation; fair 5 statement? 6 A. It is a significant symptom. Most patients will 7 deny pain. 8 Q. Well, if one is suspicious of an evolving MI and as 9 a clinician ignores the existence of complaints of 10 pressure, one's making a big mistake; fair 11 statement? 12 A. Yes. 13 Q. In the face of suspected diminishment in blood 14 supply to the heart in a patient complaining of 15 chest pressure, what does the protocol demand in 16 terms of treatment? 17 A. Typically patients receive supplemental oxygen, some 18 IV fluids, nitroglycerin, they may, if their 19 pressure and pulse would tolerate it, they might 20 receive beta blockers, aspirin. 21 Q. And if they continue to have those complaints of 22 pressure, what needs to be done? 23 A. Well, some of that medication is intensified, 24 depending on the clinical scenario, they may end up 25 getting catheterized. 59 1 Q. Which would be a step that would be taken in order 2 to identify where the problem is so that they could 3 be rushed off to either the cath lab for angioplasty 4 or to the OR for surgery, correct? 5 A. Possibly. 6 Q. So if one is seriously considering coronary artery 7 disease and ischemia as the cause of chest pain or 8 chest pressure, those are the steps that need to be 9 taken? 10 A. Yes. 11 Q. And we talked earlier about silent dissections. Do 12 you remember that? 13 A. You mean chronic dissections? 14 Q. We talked about silent dissections, I believe both 15 in the context of chronic ones and in the context of 16 acute, and I believe your testimony was -- well, 17 let's do this. I don't want to characterize your 18 testimony. 19 A. I believe I testified that -- 20 MS. REINKER: No, let him ask you a 21 question. 22 THE WITNESS: Sorry. 23 Q. What happens to the aortic valve during a Type I 24 dissection which moves proximally? 25 A. Well, it varies. I mean, nothing may happen to it, 60 1 it may become sheared off from the aortic annulus, 2 particularly at the right coronary cusp, and cause 3 sudden severe aortic regurgitation. 4 Q. In other words, regurgitation under circumstances 5 where it had moments before not been present? 6 A. It could be. 7 Q. Okay. As a clinician, is that -- if you were to 8 hear about a situation where a patient presents with 9 no evidence of an aortic related murmur on physical 10 examination and then shortly thereafter is found on 11 subsequent physical examination to have one, what 12 does that suggest? 13 A. It depends on the severity of the murmur and the 14 concomitant findings. 15 Q. Does such an interval development of a murmur 16 increase the likelihood of a dissection being a 17 potential diagnosis? 18 A. Again, it depends on the circumstances, the severity 19 and the other circumstances. 20 Q. All right. In a patient with chest discomfort and 21 in a patient with back discomfort and in a patient 22 who's had syncope and gets to the hospital or the 23 emergency room with that as part of their history 24 and who now is presenting on a second occasion with 25 a murmur that wasn't there earlier during the 61 1 emergency room visit, that development certainly 2 increases the likelihood that aortic dissection is 3 something that might be a concern? 4 A. Not necessarily. 5 Q. All right. And what you're telling me is that 6 unless the pain is severe ripping and tearing it 7 won't be a concern for a patient of yours? 8 A. Most dissections present in that manner. 9 Q. And unless they present in that manner you're not 10 going to take that as a serious consideration? 11 A. There are many other clinical details which go into 12 my decision as to whether or not a dissection is a 13 real possibility. 14 Q. Okay. So you're not going to ignore the possibility 15 of a dissection in a patient of yours just because 16 the pain isn't ripping, tearing and severe, are 17 you? 18 A. In conjunction with the remainder of my assessment. 19 Q. So I'm correct, you're not going to write off that 20 possibility just because the pain -- 21 A. Just because -- 22 Q. -- is not severe ripping and tearing? 23 A. No. 24 Q. You talk in your report, I think, of visceral 25 malperfusion at one point. 62 1 A. Uh-huh. 2 Q. How does visceral malperfusion present itself 3 clinically? 4 A. Usually severe abdominal pain and acidosis. 5 Q. Now, when Frances Broncaccio presented at the 6 emergency room here at Kaiser on the 7th of 7 December, their differential diagnosis, as you 8 understand it, was essentially one of -- that had at 9 the top of the list MI, is that how you 10 understand -- 11 A. Let me see what they wrote exactly. 12 Q. Dr. Haluska's thinking at that time -- you can look 13 at the face sheet. That's one place. 14 A. I believe his -- 15 Q. You've got it? 16 A. Yeah. Chest pain, rule out myocardial infarction 17 and bradycardia, hypotension, rule out vasovagal 18 event. 19 Q. Suffice it to say, there's significant potential 20 conditions and diseases on his differential 21 diagnosis? 22 A. Yes. 23 Q. And it would have been foolhardy and inappropriate 24 for him to trivialize the potential for harm in a 25 patient such as this presenting to an emergency 63 1 room? 2 A. Yes, trivializing anything with a patient is 3 inappropriate. 4 Q. As this patient presented, there were some serious 5 potential problems that had to be ruled in or ruled 6 out? 7 A. Yes. 8 Q. And to do that one needs to pay attention to such 9 patients and their diagnostic studies as they come 10 back, correct? 11 A. Yes. 12 Q. And that needs to be done so that one can timely 13 intervene if that's appropriate, correct? 14 A. Yes. 15 Q. And one needs to do that so that one can make sure 16 one is barking up the right tree as early as 17 possible; fair statement? 18 A. Yes. 19 Q. And by barking up the wrong tree, I think we 20 understand each other, as tests come back the 21 appropriate thing to do is look at them and by 22 looking at them make a determination as to whether 23 or not you should be considering other potential 24 diagnoses that you may not have considered yet and 25 which may not have even been appropriate to consider 64 1 until the tests come back, that's how doctors think? 2 A. Yes. 3 Q. That's how they're supposed to think, right? 4 A. Yes, right. 5 Q. Do you recall when the first enzyme study was done? 6 A. I don't, off the top of my head, no. 7 Q. I'll help you out, if I can. I'm looking at a study 8 dated the 7th with a time of 23:42 which shows a CK 9 of 212, an MB fraction of six and a relative index 10 CK/MB of 2.8. Do you see that? 11 A. Yes. 12 Q. How long does it typically take for these types of 13 studies to turn around? 14 A. Highly variable, depending on the institution, in my 15 experience. 16 Q. Well, let's talk about where you feel most 17 comfortable talking about it. Hillcrest? 18 A. Probably Parma. 19 Q. Tell me what you would expect at Parma in terms of 20 turnaround time for these cardiac enzymes. 21 A. I don't know the exact time. 22 MS. REINKER: Don't guess. 23 Q. I'm not asking you for exact time. We're not 24 talking about a day, obviously, right? 25 A. No. 65 1 Q. We're not talking about two hours, my guess is, 2 either? 3 A. It could be. 4 Q. But it typically is less than that? 5 A. Probably depends on how urgent you ask for it as 6 well. 7 Q. They can certainly be gotten within an hour? 8 MS. REINKER: Objection. 9 A. I don't know that. 10 Q. You don't know that? 11 A. No. 12 Q. Are there places if you ask for them to be done stat 13 you can get them in an hour, can't you? 14 A. Supposedly, although it can be frustrating. 15 Q. You've gotten them back in an hour in cases in the 16 past? 17 A. I have. I've also requested them to be stat and not 18 gotten them back for a long time. 19 Q. You probably made somebody know that that was 20 something that you wanted subsequently, I presume, 21 that isn't something you probably stood for without 22 making your dissatisfaction known to somebody? 23 A. I don't recall any specific event of my doing that, 24 no. 25 Q. Was the 23:42 enzyme study read by Dr. Haluska? 66 1 A. It's in his -- it's noted in his note. 2 Q. Okay. So he did read it? 3 A. Yeah. 4 Q. And if you look at the numbers that he describes, 5 those are the numbers that are in his note, the 6 first study? 7 A. Yes, they are. 8 Q. Okay. The second study numbers are not described, 9 correct? 10 A. I don't recall. 11 Q. Well, let's look at the note. If I'm not mistaken, 12 the numbers that he gives, he gives a CK of 212, he 13 gives an MB of 6, and a relative index of 2.8. 14 Those are the exact same numbers, right? 15 A. (Indicating.) 16 Q. You have to answer out loud. 17 A. Oh, yes. 18 Q. When was the second enzyme study done? 19 A. It's reported at 4:57 a.m. 20 Q. Is that when it was reported or done? 21 MS. REINKER: It's probably when it was 22 drawn. 23 A. That I don't know. The time listed is 4:57 a.m. 24 Q. I think it says C-O-L. I think that stands for 25 collected. 67 1 A. Where is it? 2 MS. REINKER: Where are you looking? 3 Q. You're looking at something that looks a little 4 different than what I'm looking at for some reason. 5 Did you ever see a page like that? Let me see 6 what you have there, if I could. 7 A. Sure. 8 Q. It looks like you've got a different set of -- 9 MR. RUF: I've never seen that. 10 MR. HIRSHMAN: We've never seen any of 11 this, I don't think. 12 Q. All right. I see what you have. 13 MR. HIRSHMAN: When we're done, Susan, 14 I'm going to ask you to copy these couple pages 15 of labs. It may just be it's printed out 16 differently. I'm not sure. 17 MS. REINKER: Okay. 18 Q. The second set of enzymes appear, to me at any rate, 19 to have been collected at 4:57. They're timed on 20 the document you have as 4:57. 21 A. Yes. 22 Q. And the numbers associated with that are a CK of 194 23 and an MB fraction of 6.6, and a relative index of 24 3.4. Is that what you have? 25 A. Yes. 68 1 Q. Do you see any evidence in the chart that those were 2 read by Dr. Haluska at any time? 3 A. I don't believe so. He doesn't note it on the 4 chart. 5 Q. So it's fair to say you see no evidence in the chart 6 to suggest that he read those? 7 A. I see no evidence to the contrary either, that he 8 did not read them. 9 Q. Well, have you ever seen a doctor write in the chart 10 I have not looked at these labs? 11 A. No. 12 Q. Do you see any evidence in the chart to suggest that 13 Dr. Ryder looked at them? 14 A. Let's see Ryder's note. They're not noted in his 15 note. 16 Q. All right. When was the second EKG done? 17 MS. REINKER: Can we go off the record 18 for a second. 19 - - - - 20 (Thereupon, a discussion was had off 21 the record.) 22 - - - - 23 A. On the record I have, she had an EKG done at 23:00 24 on the 7th. 25 Q. The second one, if I'm not mistaken -- and that one 69 1 at 23:00 is indeed documented by Dr. Haluska in his 2 dictation, correct? 3 A. I believe it is. 4 MS. REINKER: What are you looking 5 for? 6 THE WITNESS: The note. 7 Q. He describes an EKG showing a sinus rhythm rate 72, 8 axis three degrees Q wave in lead three, no ectopy. 9 Is that how you pronounce it? 10 A. Yes. 11 Q. No ischemia, no hypertrophy. That is the first EKG, 12 is it not? 13 A. It would be. 14 Q. Okay. When was the second one done? I believe at 15 5:10? 16 A. It is dated 5:10 -- or timed 5:10. 17 Q. Do you see any evidence that Dr. Haluska looked at 18 that? 19 A. He doesn't mention anything in the note. 20 Q. Do you see any evidence that Dr. Ryder looked at 21 that? 22 A. Let me see Ryder's note. No, I don't see any 23 indication that he looked at the EKG. There is 24 actually, on Ryder's note, there is a CK he does 25 says is negative on his note of 13:14. 70 1 Q. 13:14, that's the note he did after the fatal event, 2 correct? 3 A. Right. 4 Q. Is that correct? 5 A. Yes. 6 Q. And there's a third EKG that was done at 10:25? 7 A. Yes. 8 Q. Any evidence that was read by a physician? 9 A. Do you mean specifically Dr. Haluska or Dr. Ryder? 10 Q. Dr. Haluska or Dr. Ryder, let's try them. 11 A. No, I did not see any indication in their notes. 12 Q. And, of course, we can -- what you have here is an 13 interpretation which is a computer readout at the 14 top of the actual EKG, correct? 15 A. You're referring to the one from 10:25? 16 Q. Well, all three of them are accompanied by computer 17 readouts that interpret them. 18 A. Yes, it could either be the computer readout or the 19 interpretation of -- they all have an interpretation 20 by Dr. Cove or Dr. McGouch. 21 Q. Do you know when he read those? 22 A. No. 23 MS. REINKER: Or she. 24 MR. HIRSHMAN: Or she. 25 Q. And we can agree that those studies, meaning those 71 1 EKGs and those enzymes, were not indicative of 2 myocardial ischemia, were they? 3 A. No. 4 Q. And they certainly provided a clinician, if read, 5 and analyzed -- 6 A. May I correct that? They're not indicative of 7 myocardial infarction. 8 Q. Well, and the EKGs suggest no ischemia; fair 9 statement? 10 A. Yes. 11 Q. And they provide a clinician, if read and analyzed, 12 with an opportunity to rethink his diagnosis, don't 13 they? 14 A. They might. 15 Q. And if not read, that opportunity is, in essence, 16 squandered, isn't it? 17 A. If they're not read. 18 Q. Have you had an opportunity to assess how often it 19 is that Dr. Haluska saw Mrs. Broncaccio during the 20 course of her emergency room visit and CDU stay? 21 A. We know he saw her -- I did her initial physical 22 examination and I believe that he indicated that he 23 had seen her several times through her course in the 24 hospital. 25 Q. And you know that from reading his deposition? 72 1 A. His deposition, correct. 2 Q. Aside from his deposition, do you see any evidence 3 that he saw her more than once from your review of 4 the records? 5 A. Let's see if the nursing note is here. I want to 6 look very quickly at the nursing note. 7 Q. Sure. 8 A. The nurse's notes don't mention it. 9 Q. All right. So we can conclude that there's one -- 10 the emergency room chart and the CDU chart reveal 11 one instance that we can confirm of Dr. Haluska 12 seeing Frances Broncaccio, and that is confirmed by 13 his dictation where he talks about his interaction 14 with her? 15 A. Yes. 16 Q. And we can find no others in the records? 17 A. He makes no other note in the record. 18 Q. All right. And neither do the nurses? 19 A. Correct. 20 Q. Now, if you go to the nurse's notes, in fact, I'd 21 like you to do that, if you would. Before we do it, 22 this is probably a good time to take a break. 23 MS. REINKER: Off the record. 24 25 - - - - 73 1 (Thereupon, a recess was had.) 2 - - - - 3 (Thereupon, the requested portion of 4 the record was read by the Notary.) 5 - - - - 6 Q. You have the nurse's notes in front of you? 7 MS. REINKER: Which ones, the ER or 8 the -- 9 MR. HIRSHMAN: The ER nurse's notes. 10 THE WITNESS: Show me which ones. 11 MS. REINKER: It's in this section. 12 MR. HIRSHMAN: We've already looked at 13 them a couple times. There aren't that many 14 notes here. 15 Q. This nursing assessment sheet, this is what I'm 16 looking at. 17 MS. REINKER: There. 18 A. Okay. I have the same one, yes. 19 Q. At 1:00, take a look at the 1:00 note which starts 20 on page one and it goes over to page two. 21 A. Okay. 22 Q. It talks about pressure being felt and it talks 23 about the pressure being an ache like pressure, four 24 out of ten? 25 A. Uh-huh. 74 1 Q. Do you see that? 2 A. Yes. 3 Q. And then it says MD notified, I believe? 4 A. Yes. 5 Q. Doesn't it? 6 A. Yes. 7 Q. Do you see anything that documents that Dr. Haluska 8 actually came to see the patient in response to that 9 notification? 10 A. No. 11 Q. I'd like you to go to 1:05. There's a blood 12 pressure noted of 93 over 45. Do you see that? 13 A. Yes. 14 Q. That's a significantly reduced blood pressure 15 compared to what it was previously, I believe, is it 16 not? 17 A. Not in my opinion, no. 18 Q. What was it previously, 104 over 52? 19 A. 104 over 52. 20 Q. And it was enough to induce -- and we've got 127 21 over 72 on admission, don't we? 22 A. Yes. 23 Q. So that's certainly a significant decrease? 24 A. Well, blood pressure will fluctuate with time and 25 the circumstances that it's being taken under. I 75 1 would not be particularly alarmed about 93 over 45. 2 Q. Well, do you see any evidence that a nurse wanted to 3 bring it to the doctor's attention? 4 A. She indicates that she notified him of this set of 5 vitals. 6 Q. Is there any indication that he showed up to follow 7 up after that with the patient? 8 A. No, there's no note that he showed up. 9 Q. As a physician, you have to not only interact with a 10 patient, you oftentimes need to speak and interact 11 with family members as part of what you do; is that 12 a fair assessment? 13 A. Yes. 14 Q. And that's not just because you want to alleviate 15 their fears, it's also because there are occasions 16 when you can get extremely important information 17 from people other than the patient? 18 A. Yes. 19 Q. So it's often a valuable source of information not 20 only on the history of the patient, but also on the 21 complaints that the patient has expressed to family 22 members? 23 A. Yes. 24 Q. Do you know whether Dr. Haluska spoke with family 25 members as far as -- do you have any understanding 76 1 as to whether Dr. Haluska spoke with any of the 2 family members of Frances Broncaccio? 3 A. I don't remember. I don't remember. 4 Q. Do you have any recollection as to whether they 5 wanted to speak with him? I noticed that you did 6 have provided to you along with other materials the 7 depositions of Toni Bianchi? 8 A. Yes. 9 Q. And Donna Broncaccio? 10 A. Yes. 11 Q. What did they testify to as it relates to their 12 desire to talk to the emergency room physician? 13 A. Can I take a look? 14 Q. I don't want you to look because I don't think that 15 really benefits us. My guess is if you don't 16 know -- 17 A. I can't tell you specifically what was said at this 18 time. I really would have to refresh my memory. 19 Q. I want you to just assume then that they testified 20 that they wanted to speak to the emergency room 21 physician and never got the opportunity to do so, 22 okay? 23 MS. REINKER: I'm going to -- 24 objection. 25 Q. I want you to assume they asked to see the emergency 77 1 room physician, they made that request of nurses and 2 never got the opportunity to do so. Let me just ask 3 you this, does that sound like what you remember 4 reading? 5 MS. REINKER: Objection. 6 A. I don't remember specifically the -- I read two 7 daughters' accounts. As I recall, to me they seemed 8 very different at times and so I don't recall 9 specifically. 10 Q. Okay. I want you to assume that they wanted to 11 speak with Dr. Haluska and never were provided the 12 opportunity to do so, for the purpose of my next 13 question. 14 A. Okay. 15 Q. And I want you to further assume that Toni's 16 testimony -- 17 A. Okay. 18 Q. I want you to further assume that Toni testified 19 that her mother was complaining of back pain even in 20 the ER before the transfer to the CDU, okay? 21 A. Okay. 22 Q. All right. Now, if Dr. Haluska, based on those 23 assumptions, did not provide the family with an 24 opportunity to speak with him, he, in conjunction 25 with failing to provide that opportunity, failed to 78 1 provide himself with the opportunity to learn about 2 any back pain that may have been complained of by 3 Mrs. Broncaccio to her daughter; fair statement? 4 MS. REINKER: Objection. 5 A. Well, I don't know what else was going on in this 6 emergency room when she was there. I don't know 7 what his other responsibilities were or his time 8 constraints or whether he was actually notified that 9 they wanted to speak with him. I don't know that. 10 Q. So there's clearly the possibility, I suppose, that 11 a nurse did not convey that information to Dr. 12 Haluska? 13 A. It's possible. 14 Q. You would agree with me that a nurse, being asked by 15 a patient's family to talk to the doctor, has a 16 responsibility to convey that information to the 17 doctor? 18 MS. REINKER: Objection. 19 A. If she can, yes. 20 Q. And you would agree that unless this emergency room 21 was so under staffed that Dr. Haluska didn't have a 22 moment's time to follow up on that request, that he 23 indeed should have followed up on that request? 24 MS. REINKER: Objection. 25 A. I can't agree with it because I don't know what 79 1 was -- my personal experience, I have many times had 2 very frustrated families waiting for me that I could 3 not see for hours. That has happened enumerable 4 times, depending on what else is going on with other 5 patients. I don't know what Dr. Haluska's 6 circumstances were at that time. I don't know. 7 Q. Well, ultimately, though, you found the time to 8 speak to that family before leaving the hospital, I 9 presume, you wouldn't just go home without having 10 taken the opportunity to speak with the family if 11 the family wanted to speak with you? 12 A. I do my best every day in every way. 13 Q. So assuming that you're under great strain, you may 14 be in the OR, obviously you can't talk to a family 15 when you're operating on a patient, but before you 16 go home, you make every effort to speak to the 17 family members that have expressed an interest in 18 speaking to you; fair statement? 19 A. I try to contact them when I can, yes. 20 Q. And one time you would be able to would be upon 21 leaving to go home if you aren't rushing to another 22 emergency? 23 A. It could be, I mean, any number of circumstances. I 24 mean, it could be -- I've had to contact patients' 25 families late in the evening, sometimes the next 80 1 day, it does happen. 2 Q. But you make the effort to do it? 3 A. I make the effort. 4 Q. This is the time we get into the more crass issues 5 here. How much am I paying you for your time here? 6 A. Are you asking me? 7 Q. I'm asking you. Maybe I should have asked you 8 before I took the amount of time I did, but I'm 9 asking it now. 10 A. I believe it's 250 an hour. 11 Q. Okay. And is that what you charge for review of 12 records as well in this case? 13 A. Yes. 14 Q. Is that what you're charging, 250 an hour to -- 15 A. Oh, I'm sorry, I charge 250 an hour for review of 16 the records. Are you talking about to charge for a 17 deposition? 18 Q. That's what I'm paying you for. 19 A. I'm sorry. I misunderstood. I don't know exactly 20 what we're charging. I would have to get back to my 21 office, to be honest with you, not having given a 22 deposition previously. 23 Q. And I'm going to follow up on that. We talked about 24 how you had been defended by Bill Meadows, I 25 believe? 81 1 A. Yes. 2 Q. What was that about? I know it's a death. 3 MS. REINKER: Objection. 4 Q. Can you tell me a little bit more about that case? 5 A. It's a suit involving a woman who underwent an 6 esophagectomy for cancer at University Hospitals by 7 my partner and another -- a general surgeon who had 8 a very complicated postoperative course and 9 ultimately died, and by virtue of the fact that my 10 partner was one of her primary physicians, I did on 11 occasion participate in her care, although I was not 12 primarily involved, and following her death a suit 13 was filed and I was listed amongst about 30 other 14 people. 15 Q. Do you know how it was resolved or is it still 16 ongoing? 17 A. It's ongoing, although the indication I have is it's 18 being dropped. 19 Q. Let me take a moment with Mr. Ruf here and I think 20 we're close to finishing. 21 - - - - 22 (Thereupon, a recess was had.) 23 - - - - 24 Q. Are there certain risk factors that you're aware of 25 for aortic dissection? 82 1 A. Yes. 2 Q. What are they? 3 A. Hypertension, certain congenital diseases of the 4 arterial tissues, like Marfan's syndrome, 5 Ehlers-Danlos syndrome, and a couple other minor 6 ones, congenital problems of the aorta like aortic 7 coarctation, aortic aneurysm formation, those are 8 some of the major ones, actually atherosclerosis can 9 predispose to it. 10 Q. Is aortic insufficiency one? 11 A. I don't believe specifically, no. I think aortic 12 stenosis more than aortic insufficiency, as I 13 recall, and congenital aortic stenosis. 14 Q. What is the correlation between aortic dissection 15 and hypertension? In other words, what percentage 16 of patients presenting with aortic dissection have 17 an underlying hypertension? 18 A. You know, I don't recall the exact percentage, but 19 it's certainly, I think, the majority of cases, and 20 particularly associated with descending dissections, 21 but it's, I mean, a significant association. It's 22 the one that stands out in my mind. 23 Q. Is that the number one risk factor, in your 24 understanding? 25 A. Well, no. In my mind the greatest risk factor are 83 1 patients who have congenital diseases of the aortic 2 tissue, a Marfan's patient, for example, or 3 Ehlers-Danlos syndrome or some other connective 4 tissue problem. 5 Q. We've talked a lot about dissections, but I don't 6 think I asked you to tell me what the signs and 7 symptoms are of aortic dissection. 8 A. Well, we did cover some of them. We talked about 9 very precipitous onset of severe chest pain that, 10 depending on the time course, the direction of 11 dissection may radiate into the back, and then other 12 symptoms or signs that may be related to some of the 13 complications of that, loss of pulses, loss of renal 14 perfusion, gut ischemia, stroke. 15 In general, patients present, in my experience, 16 they present in extremis. Without going into the 17 details of vital signs and other studies, you can 18 talk about the gestalt that an experienced physician 19 has when he sees a patient who is ill. They 20 typically are, in general, their general appearance 21 is that of being, you know, cold, clammy, 22 diaphoretic, very uncomfortable. That aspect of it 23 is what you get, I think, with clinical experience. 24 Q. Anything else? 25 A. I think myocardial infarction they can have -- 84 1 Q. You can have a myocardial infarction by virtue of 2 shearing of the coronary artery? 3 A. Yes, particularly the right coronary artery. 4 Q. That's a rare but understood manifestation? 5 A. It can happen. They may present with tamponade. 6 There's a wide variety. 7 Q. Have you seen nausea and vomiting in a association 8 with ischemic bowel conditions? 9 A. I'm sure that it has at times been part of it, but 10 to me the hallmark of ischemic bowel is abdominal 11 pain that is out of proportion to the physical 12 exam. So when there's complaints of very severe, 13 unremitting pain and yet they have a very soft and 14 benign abdomen. 15 Q. One more question, I think, and we're done. What 16 effect would Tylenol have on a presentation of chest 17 pain? 18 A. Well, it depends on the cause of the chest pain. 19 Q. How about chest pain associated with dissection? 20 A. I doubt it would have any real effect. 21 Q. No further questions. Thanks. 22 MS. REINKER: You are requesting this 23 written, I presume? 24 MR. HIRSHMAN: Yeah. 25 MS. REINKER: You have the right to 85 1 review the transcript rather than your 2 signature just being put on it, and I also 3 suggest you take the opportunity to do that. 4 THE WITNESS: Okay. 5 MS. REINKER: Can we have an agreement 6 he can be sent the transcript and he doesn't 7 have to go to the Court Reporter's office and 8 he will get it done as fast as he can? 9 MR. HIRSHMAN: That's okay with me. 10 THE WITNESS: So a copy will be sent to 11 me? 12 MS. REINKER: Yeah. 13 14 ________________________________ JOSEPH A. LAHORRA, M.D. 15 16 17 18 19 20 21 22 23 24 25 86 1 2 C E R T I F I C A T E 3 The State of Ohio, ) SS: 4 County of Cuyahoga.) 5 6 I, Laura L. Ware, a Notary Public within and for the State of Ohio, do hereby certify that the 7 within named witness, JOSEPH A. LAHORRA, M.D., was by me first duly sworn to testify the truth, the 8 whole truth, and nothing but the truth in the cause aforesaid; that the testimony then given was reduced 9 by me to stenotypy in the presence of said witness, subsequently transcribed into typewriting under my 10 direction, and that the foregoing is a true and correct transcript of the testimony so given as 11 aforesaid. 12 I do further certify that this deposition was taken at the time and place as specified in the 13 foregoing caption, and that I am not a relative, counsel or attorney of either party or otherwise 14 interested in the outcome of this action. 15 IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal of office at Cleveland, 16 Ohio, this 12th day of March, 2001. 17 18 ___________________________________________________ Laura L. Ware, Ware Reporting Service 19 21860 Crossbeam Lane, Rocky River, Ohio 44116 My commission expires May 17, 2003. 20 21 22 23 24 25