1 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 - - - 4 G. Deloris Savage, et al., ) ) 5 Plaintiffs, ) ) 6 vs. ) Case No. 374280 ) 7 Columbia/HCA Healthcare ) Corporation, et al., ) 8 ) Defendants. ) 9 - - - 10 11 Deposition of Mark B. Landon, M.D., a witness herein, 12 called by the Plaintiffs for Examination under the statute, 13 taken before me, Candace M. Hammond, Registered Professional 14 Reporter and Notary Public in and for the State of Ohio, 15 pursuant to notice and stipulations of counsel hereinafter set 16 forth, at the University Plaza Hotel, 3110 Olentangy River Road, 17 Columbus, Ohio, on Wednesday, November 22, 2000, beginning at 18 5:40 o'clock p.m. and concluding on the same day. 19 - - - 20 21 22 23 24 25 2 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 APPEARANCES: 2 ON BEHALF OF THE PLAINTIFFS: 3 Tobias J. Hirshman, Esq. Linton & Hirshman 4 Hoyt Block Suite 300 700 West St. Clair Avenue 5 Cleveland, Ohio 44113-1230 (216) 781-2800 6 ON BEHALF OF THE DEFENDANTS, COLUMBIA/HCA HEALTHCARE CORP. 7 AND HOSPITALS AND B.J. BURTON, R.N.: 8 Mark D. Frasure, Esq. Buckingham, Doolittle & Burroughs, LLP 9 4518 Fulton Drive, Northwest P.O. Box 35548 10 Canton, Ohio 44735-5548 (330) 492-8717 11 ON BEHALF OF THE DEFENDANTS, SARN LIU, M.D.; 12 MICHAEL GYVES, M.D., JUDY NUZZA, C.N.M.; AND OUTREACH PROFESSIONAL SERVICE, INC.: 13 (Via telephone) 14 Leslie J. Spisak, Esq. Reminger & Reminger Co, LPA 15 113 St. Clair Avenue, N.E. Cleveland, Ohio 44113 16 (216) 687-1311 17 - - - 18 19 20 21 22 23 24 25 3 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 S T I P U L A T I O N S 2 - - - 3 It is stipulated by and among counsel for the 4 respective parties herein that the deposition of Mark B. Landon, 5 M.D., a witness herein, called by the Plaintiffs for Examination 6 under the statute, may be taken at this time and reduced to 7 writing in stenotype by the Notary, whose notes may thereafter 8 be transcribed out of the presence of the witness; that proof of 9 the official character and qualification of the Notary is 10 waived; that the witness may sign the transcript of his 11 deposition before a Notary other than the Notary taking his 12 deposition; said deposition to have the same force and effect as 13 though the witness had signed the transcript of his deposition 14 before the Notary taking it. 15 - - - 16 17 18 19 20 21 22 23 24 25 4 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 I N D E X 2 - - - 3 EXHIBITS MARKED 4 Deposition Exhibit No. 1 - 9 Transcript of deposition of Dr. Sibai 5 Deposition Exhibit No. 2 - 51 6 Record of warning or disciplinary action 7 - - - 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 5 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MARK B. LANDON, M.D. 2 of lawful age, being by me first duly placed under oath, as 3 prescribed by law, was examined and testified as follows: 4 EXAMINATION 5 BY MR. HIRSHMAN: 6 Q. Good afternoon or evening. 7 A. Good evening. 8 Q. My name is Toby Hirshman and we've previously 9 introduced ourselves here tonight. I represent the Plaintiffs 10 in this medical malpractice case. I'm going to be asking you 11 some questions in that capacity. Why don't we start by just 12 having you identify yourself for the record. 13 A. Mark B. Landon. 14 Q. And your home address is what? 15 A. 170 South Parkview Avenue, Columbus, Ohio 43209. 16 Q. Okay. I have in front of me some materials that you 17 reviewed, I understand, but I don't have all of them. Is that a 18 fair statement? 19 A. Correct. 20 Q. Tell me what it is that you reviewed in regard to this 21 case that I haven't been provided with. 22 A. I guess the medical record, that is to say, the 23 antepartum records and intrapartum record for Wanda Wright, as 24 well as her immediate postpartum care at St. Luke's Medical 25 Center, the neonatal records related to the case. I also 6 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 reviewed depositions of Dr. Liu, Nurse Burton, a Nurse Midwife 2 Nuza, two other additional nurses. Mr. Frasure will have to -- 3 I may have brought those. Yes. 4 Q. You brought Amerson? 5 A. Marsh -- Marsh and Amerson, A-m-e-r-s-o-n. I also 6 reviewed the depositions of Dr. Gatewood and Dr. Davis and 7 Doctor -- and you have Dr. Sibai's deposition. I think that's 8 it. I also -- Pardon me. I also reviewed reports, which we 9 spoke about before the deposition, of Dr. Gatewood and 10 Dr. Davis. Did I have those with me? I can't recall. 11 Q. You have them here. 12 A. Yes. Pardon. 13 Q. You have them here. 14 A. Thank you. 15 MR. FRASURE: You have some other reports there, don't 16 you? 17 THE WITNESS: Do I? Gemofski and a report of 18 Dr. Ashmead. 19 MR. FRASURE: And I showed you -- Did I show you 20 Tucker? 21 THE WITNESS: I think I saw a report of Dr. Tucker, 22 yes. 23 BY MR. HIRSHMAN: 24 Q. Did you see Dr. Sibai's report? 25 A. No. 7 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. All right. You indicated to me that you've seen 2 neonatal records? 3 A. Yes. 4 Q. Are you sure of that? 5 A. To my best recollection. I mean, I -- I could look. 6 Q. Yeah, take a look. I mean, if you have seen neonatal 7 records, I would like to know that. 8 A. I don't think they would have been past immediate 9 neonatal records. You know, do you know, in fact, whether there 10 were? 11 MR. FRASURE: There's prenatal. 12 THE WITNESS: No, the immediate neonatal. 13 MR. FRASURE: Here is some prenatal. 14 THE WITNESS: No. Immediate neonatal. The baby. 15 MR. FRASURE: Well, is this it? This starts 12-8-97. 16 MR. HIRSHMAN: Those are prenatal, Mark. Those are 17 the records from the prenatal care. Dr. Landon has -- 18 THE WITNESS: Let me just make it easy and say this -- 19 let me make it easy and say this, to my best recollection, I 20 thought I saw immediate neonatal records. I certainly did 21 not -- 22 MR. FRASURE: Oh, on the baby. I'm sorry. 23 THE WITNESS: I certainly have not reviewed those 24 particular records in great detail recently; so I'm doing this 25 from memory from several months ago what I thought I had 8 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 reviewed in conjunction to the case. In -- in -- To be in 2 contrast to the maternal records, which I have obviously looked 3 at more than once in preparation for these proceedings, as much 4 as the immediate neonatal records were not particularly 5 significant to the issues in the case. It is quite possible, 6 therefore, that I did not see immediate neonatal records, but I 7 assumed kind of that I did. 8 BY MR. HIRSHMAN: 9 Q. All right. 10 A. But I don't -- You know, I don't know if that helps 11 you. 12 Q. That helps. You indicated you've seen depositions of 13 Dr. Gatewood and Dr. Davis; is that correct? 14 A. Correct. 15 Q. When did you see those? 16 A. Within the last few weeks. 17 Q. Okay. 18 A. I probably read them within the last week. I don't 19 know when they were sent to me. 20 Q. And you indicated that you've seen the deposition of 21 Dr. Sibai and, in fact, you brought that with you here today? 22 A. Yes. 23 Q. And you have reviewed the deposition of Dr. Sibai, I 24 can tell from the marks that you've made in this deposition? 25 A. I have read it, correct. 9 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MR. HIRSHMAN: All right. I'm going to mark it as 2 Exhibit 1, if we can. 3 - - - 4 Thereupon, Deposition Exhibit No. 1 was 5 marked for purposes of identification. 6 - - - 7 BY MR. HIRSHMAN: 8 Q. I've had a deposition of Dr. Sibai or, I should say, a 9 deposition transcript of Dr. Sibai marked as Exhibit 1. Would 10 you kindly tell us whether that is, indeed, the transcript that 11 you reviewed? 12 A. It is. 13 Q. And the markings that appear on there at various 14 points, arrows, stars, underlinings are yours? 15 A. Correct. 16 Q. All right. You wrote a report dated August 30th, 17 2000? 18 A. Yes. 19 Q. Okay. Is that your only report? 20 A. Yes. 21 Q. Is it the only draft of your report? 22 A. The one and only, yes. 23 Q. Did you discuss this report with anyone from 24 Mr. Frasure's office, including Mr. Frasure, before signing this 25 report? 10 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. No. 2 Q. Okay. So it's entirely your input? 3 A. Certainly. 4 Q. Okay. Tell me a little bit about your past 5 medical/legal experience, if you would, starting -- starting in 6 general terms by telling me whether -- I know you have done this 7 type of work before. So tell me, if you would, something about 8 the frequency with which you've done it over the course of your 9 career. 10 A. I probably started looking at cases about a decade ago 11 or so. And over the last five or six years, that has increased 12 to a level where I might get a case or two per month to look at. 13 Q. So for the last five or six years, you've been seeing 14 approximately one to two cases a month? 15 A. In that range. 16 Q. Okay. 17 A. I have not tallied it up, but I think that's a fair 18 estimate. 19 Q. And before five or six years ago, what was the rest 20 then? 21 A. Less. Less. I'm not certain what it was, but I think 22 it was less. 23 Q. All right. What's the breakdown, if you know, between 24 plaintiffs and defendants? 25 A. I don't know the exact breakdown, but I think it's 11 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 fair to say that I reviewed cases for both plaintiffs and 2 defense firms and have never held myself out to be exclusive to 3 review for the defense or the plaintiff. 4 Q. Have you worked for Mr. Frasure before? 5 A. Yes. 6 Q. Can you tell me how many times? 7 A. A handful of times. Maybe five cases I've looked at 8 for him over the years. 9 Q. And you understand that Mr. Frasure is with a firm by 10 the name of Buckingham, Doolittle? 11 A. I do. 12 Q. Have you reviewed any cases for Buckingham, Doolittle 13 other than the ones that you reviewed for Mr. Frasure? 14 A. Yes. 15 Q. How many? 16 A. I'm not certain, but fewer than I reviewed for 17 Mr. Frasure. I reviewed for one or two other attorneys in that 18 firm a case or two at most for each of those other attorneys. 19 Q. And who are those attorneys? 20 A. Jeffrey Schobert and, I believe, an attorney by the 21 name of Lee Bell. 22 Q. Okay. Are you familiar with the firm of Reminger and 23 Reminger? 24 A. Yes. 25 Q. Have you ever worked for them? 12 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. I've been involved in cases with Reminger and 2 Reminger. 3 Q. About how many? 4 MR. FRASURE: Where they retained you or just where 5 they were involved? 6 THE WITNESS: Both ways. 7 BY MR. HIRSHMAN: 8 Q. I'm interested in those where they retained you, how 9 many? 10 A. Certainly. Reminger, a handful of times over the 11 years. 12 Q. Does handful in this instance mean the same as it did 13 in the last instance, four or five? 14 A. Well, a hand is five, so something like that. I'm 15 just ballparking it. I don't think it's more than ten. I don't 16 think it's one or two; so it's a few cases. 17 Q. Okay. I know you've testified on a number of 18 occasions on issues of shoulder dystocia, gestational 19 diabetes -- 20 A. Correct. 21 Q. -- and those issues. I want to know, however, whether 22 you've ever been involved in a case involving HELLP Syndrome? 23 A. Probably. 24 Q. Do you have a recollection of a case you were involved 25 with involving HELLP Syndrome? 13 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. No, not specifically. 2 Q. But you indicated that you had probable involvement in 3 such a case. What makes you take that position? 4 A. Well, I've looked at cases where preeclampsia has 5 clearly been an issue and I would be surprised if -- if some of 6 those cases didn't involve HELLP Syndrome as well. 7 Q. Okay. Have you testified by deposition or at trial in 8 any cases involving HELLP Syndrome? 9 A. Most likely. 10 Q. Okay. Do you recall where that testimony was? 11 A. No. 12 Q. Do you recall who you gave that testimony for? 13 A. No, I don't. It hasn't been in the last year I don't 14 think -- I don't believe, but I could be mistaken. 15 Q. All right. Now, I want to make a distinction between 16 preeclampsia and HELLP Syndrome. Do you make a distinction 17 between the two? 18 A. Well, HELLP is a variant of the preeclampsia. It's a 19 variant of severe preeclampsia. 20 Q. But, well, a severe preeclampsia can exist without 21 homolysis, elevated enzymes of the liver and reduced platelet 22 count, correct? 23 A. True. 24 Q. So when we use the term HELLP Syndrome, it's fair to 25 use it to describe that syndrome that includes those particular 14 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 presentations -- 2 A. Yes. 3 Q. -- correct? 4 A. Those features must be present. 5 Q. Those features is a better word than presentations. 6 So when we talk about HELLP Syndrome, let's talk about it with 7 that in mind. 8 A. Sure. 9 Q. Given that definition, it's still your testimony that 10 you have probably testified in cases where HELLP Syndrome was 11 involved? 12 A. I think so. I can't recall specifically, you know, 13 the name of a case or even an attorney, but I've looked at 14 enough cases that have involved preeclampsia over the last 15 several years that I would be surprised if -- if there wasn't 16 HELLP syndrome as part of, if not, more than one case. 17 Q. Okay. Let's talk for a moment about cases of yours in 18 terms of medical/legal proceedings, if any, that have been 19 brought against you. Have there been any? 20 MR. FRASURE: Objection. 21 THE WITNESS: Yes. 22 MR. FRASURE: Objection. Go ahead. 23 THE WITNESS: Yes. 24 BY MR. HIRSHMAN: 25 Q. Tell me, if you could, how many there have been? 15 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MR. FRASURE: Lawsuits? 2 MR. HIRSHMAN: Lawsuits. 3 THE WITNESS: I think three instances. 4 MR. FRASURE: Note my objection. 5 MR. HIRSHMAN: If you want a continuing objection -- 6 MR. FRASURE: That's fine. 7 MR. HIRSHMAN: -- mark, you're certainly entitled to 8 it. 9 MR. FRASURE: Sure. 10 MR. HIRSHMAN: I would gladly do that. 11 BY MR. HIRSHMAN: 12 Q. Are any pending at the moment? 13 A. No. 14 Q. So three that have been resolved one way or the other? 15 A. Correct. 16 Q. Okay. Let's start at the beginning with the first one 17 and tell me, if you would, when that was. 18 A. Oh, I think five or six years ago, something like 19 that. 20 Q. What kind of a case was it? 21 A. Claim involved failure to administer Rhogam during the 22 antepartum period. 23 Q. What is Rhogam? 24 A. It's medication given to Rh negative women to prevent 25 sensitization. 16 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MR. HIRSHMAN: Are you all right there, Les. 2 MR. SPISAK: I just smacked my knee on the table. No 3 problem. 4 MR. HIRSHMAN: You can scream. 5 BY MR. HIRSHMAN: 6 Q. What are the -- Presumably there's some negative, 7 undesirable effects associated with sensitization. What are 8 they? 9 A. Well, there can be if one has another pregnancy. 10 Q. What are the problems that occur? 11 A. That the fetus could become anemic and require in 12 utero treatment to correct anemia. 13 Q. How was that case resolved? 14 A. Dismissed. 15 Q. So you were exonerated in that case? 16 A. I was dismissed, yes. 17 Q. Okay. The next case, please. 18 A. Next case involved a claim regarding failure to 19 diagnose a fetal malformation on ultrasound examination. 20 Q. Failure to do what? 21 A. Failure to diagnose a fetal malformation on ultrasound 22 examination. 23 Q. How did that get resolved? 24 A. The case was settled. 25 Q. Money was paid in that case on your behalf? 17 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. Correct. 2 Q. Do you remember how much? 3 A. I don't know the exact figure. 4 Q. And the next case, the third case? 5 A. The third case was a similar claim involving 6 ultrasound and the detection of a fetal anomaly on ultrasound. 7 Q. And how was that resolved? 8 A. Dismissed. 9 Q. Again, as in the first one you discussed, you were 10 exonerated? 11 A. Yes. 12 Q. Okay. Who provides you with malpractice coverage? 13 MR. FRASURE: Objection. Go ahead. 14 THE WITNESS: Mutual Assurance, I believe, is the name 15 of the company. 16 BY MR. HIRSHMAN: 17 Q. Of Alabama? 18 A. I think that's correct. 19 Q. Okay. You are a maternal/fetal specialist? 20 A. Yes. 21 Q. You work out of one hospital or are there many 22 hospitals you work out of? 23 A. I work out of primarily Ohio State University 24 Hospitals, but I also consult at several other hospitals in 25 Columbus. 18 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. What other hospitals? 2 A. Riverside, Mount Carmel, and St. Ann's. 3 Q. Are there residency programs in obstetrics in each of 4 those institutions? 5 A. Yes. 6 Q. So there's 24-hour coverage with in-house 7 obstetricians in each of those institutions? 8 A. True. 9 Q. Okay. Do each of those institutions employ, as of 10 today's date, nurse midwives? And by employ, let me use it in 11 the broadest sense. I don't mean that they necessarily have an 12 employer/employee relationship. Are nurse midwives working in 13 obstetrics in each one of those institutions? 14 A. Yes. 15 Q. By virtue of your status as a maternal/fetal medicine 16 specialist, you spend your time working on high risk 17 pregnancies? 18 A. I do. 19 Q. Okay. How many hands-on deliveries do you do, let's 20 say, in a month? 21 A. Five or six. 22 MR. FRASURE: Can you hear him, Les? 23 MR. SPISAK: Six. 24 MR. HIRSHMAN: Five or six. 25 MR. FRASURE: He went up to get some coffee. Here he 19 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 is. 2 BY MR. HIRSHMAN: 3 Q. Now, is HELLP Syndrome a condition that you see with 4 some regularity? 5 A. Yes. 6 Q. Can you tell me about how often you see it in your 7 practice you see it? And by "see it", let's just restrict 8 yourself to cases you're delivering. I presumably, since you 9 told me five or six is the number that you deliver, there are 10 other scenarios where you are involved in cases where other 11 people do the deliveries? 12 A. Yes. 13 Q. Okay. So whether it's a patient that you are going to 14 be delivering or whether it's on a consultation basis or any 15 other fashion, how often do you see HELLP Syndrome? 16 A. I think somewhere on the order of a case every other 17 week or so. 18 Q. As you know, Dr. Sibai made a distinction between ELLP 19 and HELLP Syndrome. When you say "HELLP Syndrome", are we 20 talking about situations where there is not only elevated liver 21 enzymes and reduced platelet counts, but hemolysis as well or do 22 you make that distinction? 23 A. Well, I don't think I make -- make the distinction, 24 but I think I may be lumping some of those cases in together and 25 inasmuch as not every one of those cases can I tell you that a 20 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 peripheral smear has been done, for instance, or it's documented 2 hemolysis, but the clinical features are such that there is a 3 depressed platelet count, liver enzyme elevations in the setting 4 of preeclampsia and most likely represents HELLP. 5 Q. Which is the case here, indeed, isn't it? 6 A. I think so. 7 Q. Okay. Now, how often have you seen subcapsular 8 hematoma of the liver in HELLP Syndrome patients? 9 A. I've seen it, I think, three times. 10 Q. Three times in a career that began in what year? 11 A. Twenty years ago. 12 Q. Okay. And how many times have you seen a ruptured 13 subcapsular hematoma? 14 A. I think I've seen that twice. 15 Q. Okay. 16 MR. FRASURE: So this is the total of five or the two 17 within the three? 18 THE WITNESS: No. I think three cases total. 19 BY MR. HIRSHMAN: 20 Q. So you've seen three cases of subcapsular hematoma of 21 the liver, two of which ruptured? 22 A. I think that's true. 23 Q. Okay. And are those spread pretty evenly out over 24 your 20-year career? 25 A. I think so. I couldn't possibly give you dates on 21 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 them. 2 Q. No, I'm not going to ask you to. I'm a realist. Of 3 those three cases of subcapsular hematoma, how many of them 4 survived? 5 A. Two. 6 Q. One died? 7 A. Correct. 8 Q. And in what shape did those two survive? 9 A. In reasonably good shape, as far as I recall, without 10 any significant long-term impairment in their health. 11 Q. Okay. Now, you have one case of subcapsular hematoma 12 that ruptured. How did that patient do? 13 MR. FRASURE: I don't -- I think he said two, didn't 14 you? 15 THE WITNESS: Two ruptured. Of the two ruptures, one 16 died. 17 BY MR. HIRSHMAN: 18 Q. Okay. You're right. I'm wrong. You're right. That 19 is what he said. 20 Okay. Was the treatment rendered in each of those 21 cases rendered by you? 22 A. Well, I think that in one case, I think I saw it as a 23 resident and I was involved in the care. And in another case, I 24 believe I was a fellow or junior faculty. And, in the other 25 case, I think I was faculty in charge of the case. 22 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. So it's fair to say you had a hand in the care of each 2 of those cases? 3 A. Correct. 4 Q. Did each of those cases come in with a situation where 5 there had not yet been a rupture? 6 A. Well, in the one with intact, obviously. 7 Q. And the other two? 8 A. And the other two cases, no. 9 Q. They came to you, as you look at these cases in 10 retrospect, with a -- with a subcapsular hematoma that had 11 already ruptured upon presentation to the hospital? 12 A. Or was leaking, yes. 13 Q. Were diagnostic studies in the nature of imaging 14 studies done in any of those cases? 15 A. In the one case with intact hematoma without rupture, 16 yes. 17 Q. Why was an imaging study done? 18 A. Because the diagnosis, I believe, was entertained of a 19 potential liver hematoma. 20 Q. And the study done was a CT scan? 21 A. I believe that's correct, yes. 22 Q. And the CT scan revealed a subcapsular hematoma of the 23 liver? 24 A. Yes. 25 Q. And the other two did not have imaging studies done? 23 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. True. 2 Q. All right. 3 A. Yes. 4 Q. The one that did have the imaging study is the one 5 that was -- that did not -- not ruptured, as I understand your 6 testimony, correct? 7 A. Correct. 8 Q. All right. What were the -- what was the presentation 9 of this patient that induced you and your colleagues to believe 10 that a CT scan would be indicated? 11 A. I can't recall specifically in that case. 12 Q. Okay. 13 A. I mean, it's been awhile, so I would be guessing to 14 tell you exactly what her clinical presentation was. 15 Q. Would it be fair to say that the presentation of a 16 woman with HELLP Syndrome complaining of shoulder pain would be 17 an indication to perform such a CT scan? 18 A. It could be. Depending upon the -- the clinical 19 impression and the examination of the patient, it could be, yes. 20 Q. What else would you need to see in the presence of a 21 patient with HELLP Syndrome and complaints of shoulder pain 22 before concluding that a CT scan would be indicated? 23 A. Well, I think it all would get down essentially to the 24 degree of the shoulder pain. 25 Q. Okay. 24 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. And how impressed one was by the physical examination. 2 Q. Okay. The physical examination, as it relates to the 3 shoulder pain or as it relates to other matters -- 4 A. Well, let me make it simple. When we're talking about 5 pain, which is a subjective thing, I mean, people present with 6 pain who have pain in their abdomen and one entertains a 7 diagnosis, for example, of appendicitis. And they may have pain 8 in their right lower quadrant, but not everybody that has pain 9 in the right lower quadrant ends up on the operating table with 10 appendicitis. One does a physical examination and one uses 11 their experience and judgment and their skills, bedside skills 12 to make a determination this patient needs surgery, this patient 13 can be observed or I'm not very impressed with this pain, I 14 doubt it's appendicitis. 15 And the same would hold true for a woman presenting 16 with a complaint of shoulder pain even in the setting of HELLP 17 Syndrome. I mean, there might be shoulder pain, might be a 18 degree of discomfort there that would not be very impressive to 19 many seasoned practitioners or it could be very obvious that 20 this is very significant pain in the setting of HELLP Syndrome, 21 and I better think about liver hematoma and obtain an imaging 22 study. It's a clinical judgment. There's not an algorithm 23 that's easy to follow. 24 Q. So what you're telling me is that you -- 25 A. Make a bedside judgment. 25 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. -- you, as a physician, would need to make a bedside 2 judgment to determine whether or not the pain is of a sufficient 3 magnitude and concern to order the CT scan? 4 A. Right. If I thought the pain was significant, I would 5 get an imaging study. 6 Q. So what you seem to be saying to me is that a 7 description of that pain, by words that I might give you here in 8 this deposition, isn't a sufficient basis upon which you are 9 going to make that determination, you're going to make it by 10 your assessment of what's going on as you're sitting there in 11 the room with this patient? 12 A. I think that's always the case. But, you know, I 13 think if you had asked me if a patient had very significant pain 14 and used -- underlined that word significant, would you obtain 15 an imaging study, I would kind of reflectively say yes, but pain 16 otherwise without any adjective associated with it, I really 17 don't know what to do with that. I guess I would fall back on 18 what's my physical examination and how impressed am I by this 19 pain. 20 Q. Okay. I guess the bottom line is this, though, given 21 that presentation that I have gave you, a woman with HELLP 22 Syndrome who presents with pain in her shoulder, your focus is 23 going to be on ascertaining just how significant this pain is, 24 your focus is going to be on the pain? 25 A. Oh, yes. 26 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. All right. 2 A. For sure. 3 Q. All right. Let's talk about the two cases of yours 4 that you described earlier where there was a presentation with a 5 rupture of the liver capsule that had already occurred. How is 6 it, first of all, that you're able to tell me that those 7 ruptures had already occurred at the time of presentation? 8 A. Well -- 9 MR. FRASURE: In hindsight now or going back at the 10 time? 11 BY MR. HIRSHMAN: 12 Q. Obviously, with the benefit of hindsight. 13 A. One was discovered at Cesarean section and I think the 14 other one was a case of fetal distress and also discovered at 15 Cesarean section. 16 Q. That doesn't, at least to my mind, necessarily allow 17 me to conclude that when they came to hospitals, they already 18 had ruptured. What is it that allows you to say that those 19 ruptures, although obviously present at C-Section, were also 20 present some period of time that we haven't yet designated 21 earlier when those patients presented to the hospital? 22 A. I don't know. I don't think anyone would know for 23 sure exactly when in those two cases the rupture commenced. 24 Q. So what we seem to be agreeing on, maybe agreeing, 25 maybe not, we'll find out in a second here, is that you can 27 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 state with -- with a high degree of certainty that at the time 2 of C-Section they had ruptured liver capsules? 3 A. True. 4 Q. Whether or not they had ruptured liver capsules some 5 undefined earlier period of time when they presented to the 6 hospital we're not sure of? 7 A. I think that's fair. 8 Q. Okay. Did those patients, one of them got C-Sectioned 9 because of fetal distress, I think you said? 10 A. At least one of the two. And I can't recall if the 11 second one, whether there was a clinical suspicion of rupture 12 before she was opened or whether that was also fetal distress. 13 MR. FRASURE: Just looking for something. Go ahead. 14 BY MR. HIRSHMAN: 15 Q. Do you recall what was observed intraoperatively that 16 allowed the diagnosis to be made, was it blood in the peritoneum 17 or was there a concerted effort to actually visualize or palpate 18 the liver which resulted in the diagnosis being made? 19 A. No, both had blood in the abdomen. The second one had 20 a lot more blood than the first, but both had blood in the 21 abdomen. So it was not one of these cases where you palpate the 22 liver to see if there is, in fact, a hematoma present. 23 Q. Okay. Do you know how long those two women who were 24 sectioned with ruptures had been in the hospital before the 25 sections took place? 28 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. I don't recall. 2 Q. When it comes to dealing with issues like those that 3 we're about to deal with, HELLP Syndrome, hepatic rupture, and 4 subcapsular hematoma, are there certain texts that you would 5 consult to deal with those issues? 6 A. I don't think so. I mean, I wouldn't rely on the 7 texts to make management decisions if that's what you're asking. 8 I mean, I -- I'm pretty much familiar with what texts might say 9 on the subject. Although, I haven't looked it up in preparation 10 for this or in the last, you know, several months perhaps. 11 Q. And I'm particularly interested in the issue of 12 survival and -- 13 A. Okay. 14 Q. -- and intact survival. 15 A. Sure. 16 Q. If you were looking for texts that would discuss the 17 likelihood of survival, the morbidity and mortality rates of 18 patients with HELLP Syndrome with subcapsular hematoma, where 19 would you go? 20 A. Well, I probably would go online nowadays and search 21 it, but you know, past that you would go to a text and see 22 what's written by -- in the text and check the references from 23 the text. But -- 24 Q. Which -- 25 A. -- but there's information on this, you know, that 29 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 exists, not abundant information, but there's some information 2 on that subject. 3 Q. If you would -- 4 A. As I recall. 5 Q. If you would go to a text in order to start your 6 research, what texts would you consult? 7 A. I'd -- I would look at the leading texts, I would look 8 at Williams Obstetrics, I would look at Gabby's text, maybe 9 Creasy and Resnik's text. Those -- those books come to mind. 10 Q. Okay. You haven't done this type of search or 11 investigation for purposes of this case? 12 A. No. 13 Q. Okay. 14 A. I mean, I have -- I have general knowledge of the area 15 and some of the issues you raised. 16 Q. All right. Well, let's talk about it in general terms 17 then and then we'll see if we can come to some sort of 18 understanding as to the source of your understanding. What is 19 your opinion regarding the mortality rate associated with women 20 with HELLP Syndrome who present with a subcapsular hematoma? 21 A. Well, I'm not sure anyone knows the answer to that 22 question as you posed it. With rupture? 23 Q. No. 24 A. Oh, I don't think anyone knows the answer to that 25 question because simply there probably are many more hematomas 30 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 present than there are diagnosed hematomas. So whatever the 2 figure is, it's probably higher, if you follow me. If you 3 don't, I'll tell you what I mean. 4 Q. Let me tell you what I think you mean and you'll tell 5 me if I'm wrong or not. Of those women who present with 6 subcapsular hematoma, a certain number died, but not all of 7 those that present with subcapsular hematoma -- those diagnosed 8 with subcapsular hematoma may not be the entire universe of 9 those who have subcapsular hematoma? 10 A. True. 11 Q. Therefore, when counting those deaths associated with 12 subcapsular hematoma, you, by necessity, are dealing with only 13 those women who you know have the entity, correct? 14 A. True. 15 Q. Okay. So you come up with a death rate that's based 16 on the known cases of subcapsular hematoma? 17 A. So-called selection bias. 18 Q. Okay. Which may not be the entire set of women who 19 have subcapsular hematoma with HELLP Syndrome? 20 A. Right. 21 Q. And presumably that bias, as you've just described it, 22 would be a selection bias which would make the mortality rate 23 look higher than it actually is? 24 A. Yes. That's true. But it -- At the same time, you 25 might not be so interested in those women who are quote-unquote 31 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 undiscovered because they might be less likely to be symptomatic 2 and may, in fact, represent a group that really doesn't have as 3 clinically a significant hematoma, if you will. But, you know, 4 just to be fair to look at the way you posed the question, I'm 5 not sure anyone knows the answer to it. 6 Q. Okay. So you're not in a position to provide me with 7 a mortality rate for women with HELLP Syndrome known to have 8 subcapsular hematoma? 9 A. Yeah. I think that's true. I think there's a little 10 bit better data when it ruptures, but even that is not abundant. 11 Q. Let's stick with subcapsular hematoma without 12 discussing rupture yet, then we'll move on to that. We've 13 talked about mortality rates. Let's talk for a moment about 14 morbidity rates. Are you in a position to provide me with 15 morbidity rates associated with that condition? 16 A. Not specifically. 17 Q. All right. Let's move on then to subcapsular hematoma 18 that has ruptured. I want to make it pretty clear what we're 19 talking about. We're not talking about ruptured subcapsular 20 hematomas in the presence of trauma. Let's talk about what 21 we're talking about in this case, which is subcapsular hematoma 22 in the presence of HELLP Syndrome; fair way to do this you 23 think? 24 A. It's what we're talking about. Seems to be 25 appropriate. 32 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. All right. 2 MR. FRASURE: By "trauma", you mean accidental trauma 3 or trauma associated with a patient in labor? 4 MR. HIRSHMAN: We're not talking about trauma at all 5 in this case any way. 6 THE WITNESS: I think I understand Mr. Hirshman. I 7 think he wants to talk about rupture in the setting of HELLP 8 Syndrome. Rupture in the setting of HELLP Syndrome as opposed 9 to rupture from trauma, as opposed to spontaneous rupture in a 10 woman who doesn't have preeclampsia of any kind which has been 11 reported. 12 BY MR. HIRSHMAN: 13 Q. Okay. We're on the same wavelength. 14 A. And, actually, I've had a case of it. 15 Q. Can you provide me with mortality rates for women with 16 HELLP Syndrome who have ruptured subcapsular hematomas? 17 A. Well, I think older literature might have put it at 18 50, 60 percent, in that range and, you know, the more recent 19 article that everybody cites from the early '90s puts it lower, 20 but of course, I think that that's one article. I haven't seen 21 a lot on it, frankly, or that anybody has any large series. And 22 even that article, I think, went back and kind of looked at 23 other articles and grouped them together to come up with some 24 decent number in terms of a denominator. 25 Q. What article is that? 33 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. I can't -- I can't recall the author. There was -- 2 there was an article in the early 1990s on the subject. I think 3 it was in the green journal. 4 Q. That's Obstetrics and Gynecology? 5 A. I think so. I'm not positive, but that was -- the 6 vintage was sometime in the early '90s and I haven't seen 7 anything more recent that's, you know, looked at mortality rates 8 in, you know, large series, but I haven't looked for it either. 9 Q. All right. 10 A. I think in that most recent article, the mortality 11 rate was considerably lower than that, than what I stated. 12 Q. And what you stated was 50, 60 percent? 13 A. Yeah, but this more recent article was considerably 14 lower than that. 15 Q. All right. But there were clearly deaths? 16 A. Yes. 17 Q. About 28 percent? 18 A. Somewhere in the 20 percent range. I'm guesstimating. 19 Q. Okay. 20 A. But I'm just doing this from memory. 21 Q. All right. Is there any reason why we shouldn't be 22 looking prospectively at Wanda Wright as she presents and is 23 diagnosed as having HELLP Syndrome and is diagnosed as having a 24 rupture, why we shouldn't consider her -- was there any reason 25 to consider her in a light different than your typical HELLP 34 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Syndrome case that ruptures? 2 A. Boy, I don't know that there's anything typical about 3 it. It's so -- I have trouble with that adjective here. 4 Q. Because it's not a typical -- 5 A. Because it's so uncommon to begin with and to try and 6 ascribe features to any of these cases that they're so-called 7 typical of the case, when people can go a whole career and never 8 see it. A general obstetrician/gynecologist could clearly go an 9 entire career and never see this entity. So but at the same 10 time, I understand I think -- I think I understand where you're 11 coming from. I don't know that any features of her case going 12 forward, you know, were particularly distinct from, say, what's 13 been reported in the literature. 14 Q. Okay. Can we agree that she never became eclamptic? 15 "She" being Wanda. 16 A. Yes. 17 Q. Okay. 18 A. Agree. 19 Q. We can agree that when she initially presented at 20 St. Luke's Hospital, it was essentially from the get-go that the 21 diagnosis could be made of preeclampsia? 22 A. Agreed. 23 Q. Based on her blood pressure and her proteinuria? 24 A. I agree. 25 Q. And from the get-go it was obvious that what she had 35 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 was severe preeclampsia? 2 A. I think that's true based on, I think, the proteinuria 3 and some of the blood pressures. 4 Q. And there's a period of time after which laboratory 5 results come back. I think they were taken about 1:45, they 6 come back at 2:45, 2:50. Is that your recollection of how 7 things went? 8 A. Yes. 9 Q. And at that point she's noted to have an AST and ALT 10 that are clearly elevated, correct? 11 A. They were elevated, yes. At least one of the enzymes 12 came back. I don't know if they were both measured, but one of 13 them was in the mid 300s. 14 Q. Yes. Please take a look. 15 A. I think 362 or something like that. 16 MR. FRASURE: You're welcome to take a look. Don't 17 guess. 18 MR. HIRSHMAN: That's a pretty good guess actually. 19 THE WITNESS: I don't think it's a guess, but.... 20 BY MR. HIRSHMAN: 21 Q. No, it's not. It's unlikely that you would -- 22 A. If we were to guess, we might as well get on a plane 23 and go to Las Vegas. We can go play the lottery if I can guess 24 that well. 25 Q. 362 is the ALT. The AST was 678. 36 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. Thank you. 2 Q. All right. Those are both -- 3 A. Initial. 4 Q. Those are the initial liver enzymes and they're both 5 elevated, correct? 6 A. True. 7 Q. And they're both consistent with HELLP Syndrome? 8 A. Yes. 9 Q. And she had a platelet count of 90, is that what you 10 recall? 11 A. Ninety or in the low 90s. 12 Q. Again, that's a -- that's a platelet count that shows 13 that she is -- 14 MR. FRASURE: 93. 15 BY MR. HIRSHMAN: 16 Q. Is it 93? 17 A. Yes. 18 Q. Sorry. 19 A. Consistent with HELLP Syndrome. 20 Q. All right. The diagnosis was one that should have 21 been made and apparently was made at about 2:50? 22 A. True. 23 Q. Okay. Do you classify HELLP Syndrome cases based on 24 just how low the platelets go? Some people apparently do. 25 A. I haven't done that in my practice. 37 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. And, as you know, Dr. Sibai doesn't either from what 2 you've read from his deposition presumably? 3 A. Evidently not. I think people have done it more so 4 for descriptive purposes when writing up series of cases and 5 trying to report outcomes according to just how low the 6 platelets might be and how a group of women with particular 7 range of thrombocytopenia might do when compared to others. I 8 think that's really what that is about. 9 Q. So it's not really a clinical tool as much as it is a 10 research tool? 11 A. I think it would be a clinical tool. I think what 12 we're doing is attempting to describe outcomes based on how 13 significant the fallen platelets are. And if it's there and it 14 correlates, and I'm not sure it does correlate all that well, 15 one could use it prospectively, but ultimately it's not going to 16 change the care of the patient. 17 Q. Okay. You read Dr. Liu's deposition? 18 A. I did. 19 Q. Dr. Liu describes in his deposition the existence of 20 epigastric pain, does he not? 21 A. I don't recall. I have no reason to dispute that. 22 Q. All right. There's a blood-tinged urine that is noted 23 at the time of the Foley catheter being inserted, I believe. Is 24 that your recollection? 25 A. I do. 38 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. What do you attribute that to? 2 A. Well, I think it could be attributed to several 3 things. It could be trauma, it could be part of the hemolytic 4 picture, it could be concentrated urine that, in fact, could be 5 confused with blood-tinged urine or a combination thereof, which 6 is not uncommon in patients with severe preeclampsia who may 7 have reduced urine output. I don't recall what the urine output 8 was, but those are all possibilities. 9 MR. FRASURE: Les, for a fellow that's hit his knee, 10 you're doing pretty well. 11 MR. SPISAK: I'm sitting here writing in pain 12 silently. 13 BY MR. HIRSHMAN: 14 Q. Did Dr. Liu, in your opinion, have an obligation to 15 come in and see this patient? 16 A. Oh, I think so at some point, yes. 17 Q. Did Dr. Liu have an obligation to come in and see 18 Wanda Wright prior to the time that he came in? 19 A. I think probably, yes. 20 Q. And why is that? 21 A. Well, I think that at some point it became clear that 22 she had HELLP Syndrome and if he was requested to come in, 23 certainly he should have. 24 Q. Are you suggesting that the -- that he had no 25 obligation to come in until Judy Nuza specifically said to him, 39 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 I'm in over my head, would you please get in here? 2 A. Well, if she said that, those words to him, I think he 3 clearly had an obligation to come in at that point. I think 4 whether he should have come in earlier or not would have pretty 5 much depended upon the conversation between Nurse Midwife Nuza 6 and himself and as to her comfort level as well as his 7 impression from the facts that she was relaying to him about the 8 condition of Wanda Wright, but I think that would be the issue 9 in deciding whether he needed to come in at 2:00 versus 3:00 or 10 something like that. 11 Q. Well, let's go through some sort of a set of scenarios 12 then. Let's assume that at 1:45 Dr. Liu is called, he's told 13 that the patient is there and he's responsible for this patient, 14 by virtue of him being on call. Let's assume that he is told by 15 Judy Nuza that the patient has presented with a blood pressure 16 that's 200 -- 207 over 100 and plus four proteinuria was found 17 as well. And further assume that there's nobody in the hospital 18 as an OB, although, there is a nurse midwife. Did he have an 19 obligation to come in at that time? 20 A. I think he certainly could have come in at that time, 21 but in terms of when -- I think he probably needed to see what 22 her blood pressure did over a brief period of time after that 23 before making that decision. 24 Q. All right. 25 A. To see if her blood pressure settled down at all, and 40 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 I think that would be the point in time where it would be 2 important for him to make a decision to come in or not. 3 Q. How often should those blood pressures have been 4 taken? 5 A. Well, I think certainly another blood pressure, say, a 6 half hour or so later if it were, again, significantly elevated, 7 I think it would be of benefit for him to be there. It would be 8 of benefit in the event that there was an emergency that he 9 would be on site. That would be the benefit, the principal 10 benefit. 11 Q. Okay. The benefit is one that we can probably simply 12 describe in this fashion, a nurse midwife has no ability to 13 deliver a baby by C-Section, right? 14 A. That's the issue right there. 15 Q. And a nurse has no ability to deliver a baby by 16 C-Section, correct? 17 A. True. 18 Q. Okay. And certainly by 2:50, where there is -- is it 19 your understanding that there was a second phone call at about 20 2:45 or 2:50 in the morning? 21 A. I think so, in that range. 22 Q. At that point in time, if we assume that yet another 23 blood pressure was communicated to Dr. Liu and that this time 24 the blood pressure was 217 over 112, and if we further assume 25 that at that time the elevated liver enzymes and the reduced 41 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 platelet count were also communicated to him, we can agree that 2 he had an obligation to get into the hospital? 3 A. I think so. 4 Q. And we can say without any question that if that were 5 you, you would have been in your car and on your way to the 6 hospital? 7 A. True. 8 Q. All right. And to not have done so constitutes 9 departure from the acceptable standards of care? 10 A. I think that's true. 11 Q. Okay. Now, as it relates to doctor -- treatment that 12 was given, we can agree that a review of the records and of Judy 13 Nuza's deposition reflects that she wanted to start magnesium 14 sulfate immediately and, in fact, she wrote it in the record 15 anticipating that was going to be done? 16 A. True. 17 Q. And that subsequent to her first conversation with 18 Dr. Liu at 1:45 in the morning, she was told to hold the 19 magnesium sulfate and, as a result, she crossed it out and did 20 not give it, right? 21 A. Correct. 22 Q. And magnesium sulfate was, accordingly, not started 23 until sometime after 3:00 in the morning, correct? 24 A. In that range, yes. 25 Q. And why is magnesium sulfate prescribed for a woman 42 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 presenting with preeclampsia -- severe preeclampsia? 2 A. To prevent convulsions. 3 Q. And what is so terrible about convulsions? 4 A. Well, the convulsions can be associated with a risk to 5 the mother of neurologic events, they could be associated with 6 the risk of aspiration, and they can be associated with hypoxia, 7 which can affect the fetus as well. 8 Q. They can cause neurologic injuries to the mother and 9 to the child? 10 A. Correct. 11 Q. Okay. Mag sulfate should have been started 12 immediately, should it not have? 13 A. More or less. 14 Q. And it was not? 15 A. True. 16 Q. Do you have an opinion as to whether that constitutes 17 a departure from acceptable standards of care? 18 A. I do. 19 Q. And what is your opinion? 20 A. It does. 21 Q. And who is it who departed from acceptable standards 22 of care, Judy Nuza or Dr. Liu or both? 23 A. In this instance, Dr. Liu. 24 Q. All right. Now, these blood pressures are severe -- 25 severely elevated blood pressures, are they not? 43 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. Some of them, yes. 2 Q. All right. They were not treated, were they? 3 A. Not with anti-hypertensive therapy, correct. 4 Q. The only thing that was done was that ultimately at 5 sometime after 3:00, magnesium sulfate was given, which some 6 might argue can have some anti-hypertensive affect, but 7 certainly isn't anywhere near the optimal drug, correct? 8 A. Not designed to be an anti-hypertensive, true. 9 Q. And in this case, if it did have an anti-hypertensive 10 affect, it was minuscule at best, correct? 11 A. I don't -- I don't think it had a significant affect. 12 Q. All right. 13 A. Nor was it delivered in order to be an 14 anti-hypertensive. I don't believe that's been anyone's 15 testimony, if I'm not mistaken. 16 Q. Can you think of a -- Well, anti-hypertensive 17 medications should have been given to Wanda Wright? 18 A. I think at some point, yes. 19 Q. Anti-hypertensive medications should have been given 20 to Wanda Wright as of what time? 21 A. I would have to go back and look at the blood 22 pressures to be specific about that, but I think once it became 23 evident that her diastolic blood pressure, in particular, was 24 sustained elevated, say, over 110, pretty much the standard 25 would be to administer some anti-hypertensive therapy. 44 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Let's see if we can establish what is there in terms 2 of blood pressures. They did not do many, did they? They did 3 essentially no more than one an hour? 4 A. Something on that range, yes. 5 Q. They did one at 1:15 of 207 over 100, as we've 6 indicated, one at 2:10 of 217 over 112, they did one at 3:00 7 of -- 8 THE WITNESS: Do you have that, Mark? 9 MR. FRASURE: Yes. 10 THE WITNESS: Mark has it here. 11 MR. FRASURE: Maybe he does. 12 BY MR. HIRSHMAN: 13 Q. Of -- Here we go. 195 over 114. And then they did 14 one at 4:00 of 206 over 111. When should anti-hypertensive 15 medication have been started? 16 A. I think somewhere around 2:00 with that second 17 reading. 18 Q. Do you agree with Dr. Sibai that within one half hour, 19 it would be expected that those anti-hypertensive drugs would 20 have reduced her blood pressure to acceptable levels? 21 A. I think so in most cases. 22 Q. Okay. And failure to start that anti-hypertensive 23 medication at 2:00 constituted departure from acceptable 24 standards of care? 25 A. True. 45 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Aside from the departures from acceptable standards of 2 care that we have now discussed, have you found any other 3 departures from acceptable standards of care on the part of 4 Dr. Liu? 5 A. I don't think so. 6 Q. What's your understanding as to Judy Nuza's 7 familiarity with HELLP Syndrome? 8 A. I think she testified that she didn't have too much 9 experience with HELLP Syndrome, if I'm not mistaken. 10 Q. Is it, in fact, is it your recollection that she 11 testified to a need to go to the library in order to research 12 the syndrome during the course of her care and treatment of 13 Wanda Wright, is that your recollection? 14 A. I think so. 15 Q. Okay. Would it be fair to say that those 16 circumstances only underline the need for Dr. Liu's presence at 17 the hospital? 18 A. They would support that. 19 Q. You're aware that a notation was made in the chart at 20 3:50 regarding shoulder pain by Nurse Burton? 21 A. I think she described shoulder cramps, yes. 22 Q. And she describes that description, according to Judy 23 Nuza, was never relayed to her verbally, orally, correct? 24 A. That's my understanding. 25 Q. And is it your recollection that Judy Nuza expressed a 46 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 regret about that fact in her deposition? 2 A. I think, in retrospect, she did express that. 3 Q. And obviously Judy Nuza had the opportunity to look at 4 the records to see if that -- to find that note regarding 5 shoulder pain, but apparently did not, correct? 6 A. She did have the opportunity. 7 Q. Did, in your opinion, Nurse Burton have an obligation 8 to orally communicate that shoulder pain complaint or shoulder 9 cramp complaint to the nurse midwife? 10 A. I don't think she did if she wasn't particularly 11 impressed with it. And if it seemed to subside and was not 12 persistent, I don't think she did. On the other hand, if it 13 were persistent pain, and one that did not seem to go away with 14 some -- with some period of observation of time, then I think 15 she would be remiss not informing, pardon me, Nurse Nuza -- 16 Nurse Midwife Nuza. 17 It kind of gets down to this whole issue of, again, 18 assessment of pain in a particular patient and how significant 19 the pain appears to be, how uncomfortable the patient is and 20 how -- and whether the pain persists, in particular. 21 Q. Given what we know with the benefit of hindsight, we 22 know that this liver ruptured, and we know that there was a 23 complaint of shoulder discomfort or pain which is described as 24 cramping and which is described as a cramping which is causing 25 this patient to roll from side to side, which presumably 47 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 suggests a significant pain, does it not, or a significant 2 discomfort? 3 A. Again, I think -- I would defer to Nurse Burton as to 4 how significant of pain the patient was in. It's not clear to 5 me. I know that there's one notation on it. I don't know from 6 the medical record if it was persistent pain and how impressive 7 the pain was per se. Clearly, if it was impressive pain that 8 did not resolve with some treatment. And I think, if I'm not 9 mistaken, Nurse Burton attempted to, you know, massage the 10 patient to see if her pain relieved and reported it did, then it 11 might not be a significant finding to report at all. But if it 12 persisted, it would be a significant finding. 13 In retrospect, it could be the -- could have been a 14 very significant finding, with the benefit of hindsight, if -- 15 if, indeed, that -- that reflected blood under the diaphragm 16 were further stretching of her liver hematoma. 17 Q. But in our perspective today, do you have an opinion 18 as to that -- as to whether that was what was going on there? 19 A. I think it's possible. I think it's very possible in 20 retrospect that that was the case, but I just -- without -- 21 without having observed the patient to see if that pain 22 continued throughout the next hour or hour and a half, in an 23 unrelenting, significant and escalating fashion, it would make 24 it difficult for me to say whether that, indeed, was the 25 etiology of the pain. 48 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Okay. Does a nurse have an obligation to report the 2 type of cramping that is related in the record to the nurse 3 midwife or physician in your opinion? 4 A. Depends upon how significant the finding appeared to 5 be at the time. 6 Q. Do you have an opinion as to whether the amount of -- 7 whether the findings that existed at the time were such as to 8 require that sort of reporting orally? 9 MR. FRASURE: I thought we've been over all of this, 10 but go ahead. 11 THE WITNESS: From the record, I don't think it's 12 clear. 13 BY MR. HIRSHMAN: 14 Q. All right. Have you had a chance to look at the fetal 15 heart monitoring strip? 16 A. I did. 17 Q. Do you have it with you? 18 MR. FRASURE: I was looking through my file. I don't 19 think I brought that. If you have it -- 20 MR. HIRSHMAN: I have it. 21 THE WITNESS: You let me down. 22 MR. FRASURE: Well -- 23 BY MR. HIRSHMAN: 24 Q. Here we go. I'll provide you with my copy. 25 A. You don't have to take it out. I'm going to come 49 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 over. 2 Q. I'm not going to take it out. 3 (Discussion held off the record.) 4 THE WITNESS: I'm ready, I think. 5 MR. SPISAK: Actually, Toby, you have to hurry up 6 because I've got to go have some surgery on this knee. 7 MR. HIRSHMAN: I feel for you. 8 MR. SPISAK: Thank you. 9 BY MR. HIRSHMAN: 10 Q. Do you agree -- when did -- when did the -- when do 11 the fetal monitoring strips show a circumstance requiring 12 nursing intervention as it relates to the fetal heart monitor? 13 A. Certainly by 4:30 and maybe a little bit before that 14 time. I don't have times on this, so I -- on some of this. 15 Somewhere between 4:00 and 4:30. 16 MR. FRASURE: There are times on there. 17 THE WITNESS: I see them now. 18 BY MR. HIRSHMAN: 19 Q. And when is it your understanding that nursing 20 intervention first took place? 21 A. Let's go back. I think about 4:36, there was clearly 22 recognition of potential nonreassuring fetal status. 23 Q. And that's a rather significant period of time without 24 nursing response to a worrisome strip, is it not? 25 A. Well, I think you may have a gap of 15 minutes or so, 50 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 maybe 15, 20 minutes. 2 Q. Isn't that a -- the type of response you would 3 encourage nurses working with you to provide? 4 A. No. I mean, you would like to pick up any heart rate 5 changes as soon as they're occurring, but I don't think that 6 things become -- become really significant until just shortly 7 before 4:30, maybe 4:25. 8 Q. That's when we start seeing a real bradycardia 9 developing, don't we? 10 A. I think the bradycardia begins at about -- Let's see, 11 maybe around 4:37. 12 Q. Okay. 13 A. I'm talking about a sustained -- 14 Q. What do you see -- I'm sorry, I interrupted you. 15 A. I'm sorry, sustained decline in the fetal heart rate, 16 as opposed to decelerations. 17 Q. So at 4:25, there are decelerations that concern you? 18 A. Yes. 19 Q. By 4:37, what we have is a bradycardia? 20 MR. FRASURE: 4:37 or 4:27? 21 THE WITNESS: 4:37. 22 BY MR. HIRSHMAN: 23 Q. 4:37, correct. 24 A. That's the way it appears, yes. 25 Q. And from sometime even earlier than that, we have 51 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 signs that should have been responded to by the nurses and 2 weren't, correct? 3 A. I think they should have been noted, yes. 4 Q. Okay. Have you been provided with a copy of the 5 disciplinary action that was taken against Nurse Burton? 6 A. No. 7 MR. HIRSHMAN: We're going to mark this as Exhibit 2. 8 MR. FRASURE: Note my objection, but go ahead. 9 - - - 10 Thereupon, Deposition Exhibit No. 2 was 11 marked for purposes of identification. 12 - - - 13 MR. FRASURE: On the basis of a subsequent remedial 14 measure and/or peer review. 15 BY MR. HIRSHMAN: 16 Q. I'm handing you what's been marked as Landon 17 Deposition Exhibit 2. I'll simply ask you whether this is the 18 first time you've ever seen this document? 19 A. Yes. 20 Q. All right. Do you disagree with Item No. 3? 21 A. No. 3. Let's see, again, I think I've testified to 22 this that it -- it really -- I don't think the nurse is 23 obligated to make the physician or the nurse midwife aware of 24 every discomfort that the patient experiences. I think it has 25 to be taken in context as to whether the shoulder cramp was more 52 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 than a cramp and was sustained discomfort that could not be 2 relieved in any way as to whether it was significant or not. I 3 think -- I think I may have had it clear that if the judgment 4 was that this was significant pain, that it should have been 5 reported. 6 Q. And do you disagree with Item No. 4? 7 A. No. 4. 8 MR. FRASURE: Which one is 4, Doctor? 9 THE WITNESS: "At 4:20, the fetal heart rate decreased 10 to the 70s with no nursing interventions until 4:40". 11 MR. FRASURE: Put that in quotes. He is reading. 12 THE WITNESS: "When certified nurse midwife was 13 notified by another R.N." 14 MR. FRASURE: End quote. 15 BY MR. HIRSHMAN: 16 Q. Disciplinary action was taken against Nurse Burton for 17 that set of circumstances. Do you disagree with that 18 disciplinary action being taken? 19 A. I think because -- I'm sorry. I think -- Can I 20 answer? 21 Q. Go ahead. 22 A. I think, as I've indicated, I think there was some 23 delay of some minutes in this case from 4:27, this report says 24 4:20, my eye says more 4:25, 4:27, but close to that period of 25 time when there appeared to be no interventions until the Nurse 53 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Midwife Nuza was notified at 4:40. 2 Q. So with the exception of you feeling that the time was 3 perhaps a few minutes shorter than is indicated on the 4 disciplinary notice, you otherwise agree with the -- the 5 notations made in that disciplinary notation? 6 MR. FRASURE: On that item? 7 BY MR. HIRSHMAN: 8 Q. On that item? 9 A. I don't -- I don't know. You know, it -- it's 10 difficult for me to say what was or wasn't done at that -- in 11 that brief stretch of 10 minutes or so. 12 Q. Let's assume nothing was done. 13 A. Okay. If we assume nothing was done, yes. That would 14 be -- that would be problematic, but we're talking about a 15 10-minute period of time here and I'm not certain what was or 16 wasn't done in -- in the span of 10 minutes except to say that 17 there is some entry that they're attempting to reach fetal heart 18 rate with ultrasound and so forth. So there is some concern 19 there. It's not being totally -- To be fair, it's not being 20 totally ignored by the treating nurses that there is a problem 21 with the fetal heart rate. 22 Q. What are you reading from, what time period? 23 A. I'm reading from an entry here, again, at 4:36. 24 Q. Okay. Prior to that time, do you see any evidence 25 that anything was being done? 54 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. Again, you know, I'm talking about that 10-minute 2 period of time, but maybe they were doing it and didn't have 3 time to enter it. I mean, it's such a brief period of time, 4 I -- I'm not sure that I would be critical of that in -- in that 5 there wasn't an entry regarding what was done during that period 6 of time. They may have been doing something and been busy 7 enough not to have the time to even enter it. I mean, they 8 could spend their whole time entering it if they wanted to go 9 minute by minute here. 10 Q. Okay. If we assume that there is nothing that was 11 done from 4:25 to 4:35, you would be critical of that fact? 12 MR. FRASURE: I guess below the standard of care? 13 MR. HIRSHMAN: We'll get to that. 14 MR. FRASURE: Okay. Go ahead. 15 THE WITNESS: I think I believe that attention should 16 have been made -- paid, excuse me, to the heart rate changes at 17 that point in time and that would involve positioning the 18 patient, administering oxygen and so forth. 19 BY MR. HIRSHMAN: 20 Q. Would you agree that the failure to do so constitutes 21 a departure from acceptable standards of care for a nurse in an 22 obstetrical unit? 23 A. I think after a period of time, yes. It -- If one has 24 a heart rate pattern like that, failing to make some effort 25 along those lines would be beneath the standard of care. 55 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Failure to do it within the 10-minute period of time 2 that we've just described would constitute a departure from 3 acceptable standards of care, correct? 4 A. I don't know if that's entirely true. It's a brief 5 window. I -- I suppose that if they did nothing, it would be 6 beneath the standard of care. Exactly what they should have 7 done, is started to reposition the patient and administer 8 oxygen. I'm sure we could get a half a dozen people in here and 9 some people would put it at 4:25 and some people at 4:20 and 10 some 4:28. We're in a very narrow window of time here. 11 Q. Do you have an opinion as to the cause of the fetal 12 bradycardia? 13 A. I think it's likely associated with internal bleeding. 14 I mean, in retrospect, that seems to make sense. 15 Q. Did you consider any other alternative causes? 16 A. Sure. 17 Q. What did you consider? 18 A. I mean, you could have -- that could be secondary to 19 an abruption, that could be secondary to a cord compression. 20 Q. Did you consider any others? 21 A. Not offhand. 22 Q. Okay. When Dr. Liu didn't come in, did, in your 23 opinion, Nurse Burton have an obligation to implement a -- a 24 chain of command request for assistance? 25 A. I don't think so in this case. 56 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. And why is that? 2 A. Well, I think you have the situation here where you 3 have Nurse Midwife Nuza more or less interposed between -- 4 between Nurse Burton and Dr. Liu and is essentially functioning 5 as the primary care provider in house for Wanda Wright and is 6 also the individual that's in communication with Dr. Liu and, to 7 some extent, how she communicates to Nurse Burton regarding her 8 feelings concerning the situation would ultimately come into 9 play as to whether Nurse Burton would view the situation as one 10 in which she needed to take action along those lines. 11 Q. If I understand what you're saying then, it's this, 12 since Nurse Nuza was there, and since Nurse Nuza was the nurse 13 midwife and since Nurse Nuza was the one interacting with 14 Dr. Liu, that any requirement for that sort of appeal to a 15 higher authority should have been done by Nurse Nuza? 16 A. I think so. If it were going to be done at all in 17 this case. If Nurse Nuza wasn't there, for example, and this 18 patient presented with HELLP Syndrome or high blood pressure and 19 severe preeclampsia for that matter and it was Nurse Burton on 20 the phone with Dr. Liu reporting the facts and -- and expressing 21 concern over the patient's condition, and Dr. Liu failed to come 22 and Nurse Burton then failed to bring into play her superiors or 23 chain of command, for lack of a better term, then this would all 24 make sense. 25 But you have a case here where you have a nurse 57 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 midwife who is really the communicator and the on-site hands for 2 that physician. And unless that nurse midwife is -- is 3 essentially so out of sorts about the situation and clearly 4 expressing that to Nurse Burton, I don't know that Nurse Burton 5 would have the sense that this is a situation where we've got 6 such a major problem here that this physician is not coming in 7 despite Nurse Nuza's request and I need to do something about 8 this. 9 Q. Okay. So if I can characterize this -- this in a 10 nutshell, Nurse Nuza had an obligation to implement a chain of 11 command request? 12 MR. FRASURE: In the abstract or in this particular 13 patient? 14 MR. HIRSHMAN: I'm talking about in this case. 15 MR. FRASURE: Under these facts? 16 BY MR. HIRSHMAN: 17 Q. Under these facts. 18 A. I think, again, if she were uncomfortable with the 19 situation, if she felt unsure of herself and felt that she was 20 potentially compromising the care of Wanda Wright, yes, I think, 21 you know, she had the obligation with that -- in that regard and 22 clearly eventually when it became clear that the patient needed 23 to be delivered and Dr. Liu wouldn't be readily apparent, if I'm 24 not mistaken, she got Dr. Gyves there. So she had that ability 25 all along. 58 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. So we know from what happened at somewhere after 5:00 2 that there was a means available to go around Dr. Liu, correct? 3 A. Or beyond Dr. Liu, if you like, yes. 4 Q. Would it be fair to say that if -- 5 A. Let me just say, I mean, it speaks for itself. The 6 ability was there to do it, it was done. I don't see how the 7 burden falls on Nurse Burton to have done that when, in fact, it 8 was done in this case and could have been done earlier by the 9 individual Nuza. 10 Q. When should it have been done by Nuza? 11 A. Well, I think probably as soon as Nuza felt that Liu 12 should have been there, which was a little bit earlier in the 13 evening or when it became apparent the patient had HELLP 14 Syndrome and she didn't have experience with HELLP Syndrome and 15 was uncomfortable with the situation. 16 Q. All right. You don't have any criticism of Dr. Gyves, 17 I take it? 18 A. No, no one seems to. 19 Q. And, in your opinion, he did not depart from 20 acceptable standards of care? 21 A. Correct. 22 Q. And do you have any criticism of the way that Wanda 23 Wright comported herself, did she -- are you familiar with the 24 term contributory negligence? 25 A. Yes. 59 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. She -- Was she contributorily negligent in any fashion 2 in this case? 3 A. Not to my reading of the record. 4 Q. Okay. Based on -- I want you to assume that you were 5 involved in this patient's care, that Wanda was a patient of 6 yours and that, unlike Dr. Liu, you saw a need to come in, and 7 came in and were attending to her. I want you to further assume 8 that you had, in addition to the records, you had the fetal 9 monitor strip available to you. Is there a time that you would 10 have decided that there was need to do a Cesarean section? 11 A. I think that, if I'm not mistaken, I thought that the 12 bradycardia -- 13 MR. FRASURE: If you want to look again. 14 THE WITNESS: I thought the bradycardia looked like 15 around 4:37. 16 MR. FRASURE: Let's be precise. I don't want you to 17 guess. 18 THE WITNESS: I'm sorry to burden you with that again. 19 BY MR. HIRSHMAN: 20 Q. You're not burdening me. We're both here -- 21 A. Thanks. 22 Q. -- and this is what we're doing. 23 A. Right. Where was that again? 24 Q. Oh, keep going if you're looking for the strip. 25 A. Yeah. 60 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. There's a little tab there that says "fetal monitoring 2 strip". 3 A. Okay. All right. Looking at the strip, not long 4 after 4:30 when the bradycardia is evident, I'd like to be 5 moving the patient and getting things going, so to speak. 6 Q. How long would it have taken you to do a -- assuming 7 you were there -- 8 A. Sure. 9 Q. -- assuming that there was an in-house 10 anesthesiologist, how long would it have taken you to deliver 11 this child? 12 MR. FRASURE: To cut? 13 BY MR. HIRSHMAN: 14 Q. To make the incision. 15 A. Okay. Let's say I move the patient at -- at about 16 4:35 or thereabouts. 17 Q. All right. 18 A. It takes a few minutes to move. I'm in the room a 19 little bit before 4:40, I have an anesthesiologist in hand. I'd 20 hope that I'd be making my incision no later than 10 minutes 21 later or so, but it might take longer. I mean, it just would -- 22 a lot would depend upon the mother's blood pressure and 23 anesthesiologist and so forth. But in the best of 24 circumstances, I'm in the room at 4:40 and I'm making the 25 incision in, you know, five minutes. 61 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. And within a minute of the incision, you would have 2 had this baby delivered? 3 A. A minute or two, yes. I don't -- I can't recall how 4 big she was and whether she had any prior abdominal surgery off 5 the top of my head, but these are factors that might limit your 6 ability to get a baby out in a minute or two. 7 Q. Assume no prior abdominal surgeries. 8 A. Yeah. 9 Q. No adhesions, no problems along those lines. 10 A. True. I'd like to get it out in that time frame. 11 Q. Okay. 12 A. I'm reluctant to give this back to Mr. Hirshman 13 because I have a feeling I'm going to need it again. 14 Q. Keep it right there. 15 A. I'll put it down here. 16 Q. That's fine. Let me ask you some questions we started 17 alluding to on a more generalized basis before, now we're going 18 to talk about them as it relates to Wanda Wright. It's your 19 opinion that she had hepatic hemorrhage upon presentation, 20 correct? 21 A. I think so. 22 Q. That's what you write in your report. Is it your -- 23 Do you have an opinion as to when she -- We talked briefly about 24 leakage versus rupture. I take it they're not the same. 25 A. Well, I think leakage just means that there's not 62 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 hemorrhage to the degree to lead to cardiovascular compromise or 2 the potential for collapse, but I think you could -- leaking 3 implies that the capsule has been violated and that there's 4 technically rupture present. 5 Q. All right. Do you have an opinion as to when -- Let's 6 start with rupture. Let's -- Maybe we need to define the term a 7 little bit better first. You can have leakage -- Can you have 8 leakage of the liver without a frank loss of integrity of the 9 capsule? 10 MR. FRASURE: Talking about leakage from the liver or 11 leaking from the capsule surrounding the liver? That's what I 12 always get confused about. 13 THE WITNESS: He has a tough time with anatomy. 14 MR. HIRSHMAN: I do, too. 15 MR. FRASURE: Thank you. 16 MR. HIRSHMAN: If the liver is leaking. 17 MR. FRASURE: I was thanking Toby. 18 BY MR. HIRSHMAN: 19 Q. Well, absent a crack in the liver capsule, can you 20 have the loss of blood from the liver? 21 A. I don't think so. 22 Q. Okay. 23 A. I don't see how. 24 Q. All right. So there's no transudation sort of a 25 process that you can think of? 63 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. Transudate wouldn't be blood, it would be like serous 2 fluid. 3 Q. All right. So in order for there to be, in your 4 opinion, a loss of blood from the liver, there has to be some 5 sort of a loss of integrity of the capsule? 6 A. Yes. 7 Q. Physical loss of integrity in the nature of either a 8 rent or a tear or a gaping hole? 9 A. True. 10 Q. All right. So I take it the process by which a 11 rupture occurs isn't necessarily an explosion or is it? 12 A. True. 13 Q. Do you have an opinion as to how it is that the loss 14 of integrity of Wanda's liver evolved in this case? 15 A. I think she had this syndrome of HELLP Syndrome, I 16 think she had involvement of her liver through this process that 17 led to areas of hemorrhage within the parenchyma of the liver 18 some in proximity to the surface of the liver that eventually 19 gave way and led to hematoma formation. 20 Q. Subcapsularly? 21 A. Subcapsular, yes. 22 Q. As that subcapsular hematoma grew, it exerted greater 23 pressure on the capsule until the point that the capsule 24 actually gave way, correct? 25 A. I think that's what happens. 64 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. All right. Do you have an opinion as to whether that 2 capsule had given way and lost its integrity at a particular 3 time? 4 A. Well, the only thing we know is that there was quite a 5 bit of blood in the abdomen at the time of the Cesarean and it 6 clearly ruptured. In retrospect, she had some change in her 7 sensorium, I think, shortly after 5:00, if I'm not mistaken. 8 And then we have the fetal heart rate changes in the 9 neighborhood of 4:30 or so, which would again, in retrospect, 10 fit with blood loss, and perhaps hypoperfusion of the uterus and 11 placenta leading to those heart rate changes. So somewhere in 12 that range of time did she begin to have significant bleeding in 13 the abdomen. She may have had it before that, I mean, but 14 not -- not massive. 15 Q. So it's your opinion, to a reasonable medical 16 probability, that by -- I'm going to work backwards. I'm going 17 to start with the times that I think you may be more comfortable 18 with and then work back. 19 MR. FRASURE: Kind of pushing it. Go ahead. 20 BY MR. HIRSHMAN: 21 Q. It's your opinion that certainly by 5:29, to a 22 reasonable medical probability, Wanda had suffered a rupture of 23 her liver? 24 A. True. 25 Q. That's when the baby was born, 5:29? 65 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. True. 2 Q. Okay. Do you have an opinion, to a reasonable medical 3 probability, as to whether or not there was a rupture of Wanda's 4 liver at 5:00 in the morning? 5 A. I think there probably was. 6 Q. Do you have an opinion, that you hold to a reasonable 7 medical probability, as to whether Wanda's liver had ruptured at 8 the time of the fetal bradycardia? 9 A. A very good chance that that's true. 10 Q. Are you able to state that opinion to a reasonable 11 probability? 12 A. I think -- I think so. 13 Q. All right. 14 A. I can't be as certain as -- as the two former 15 questions. 16 Q. All right. Okay. Are you able to tell me whether at 17 3:50 in the morning Wanda's liver had ruptured to a reasonable 18 medical probability? 19 A. I don't know. I don't know that that's true. She may 20 have had some leaking then. 21 Q. But you won't give me that opinion to a reasonable 22 medical probability? 23 A. I don't think I can. 24 Q. Okay. 25 A. I think it's a guess at that point. 66 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. And certainly any earlier than that, your guesses 2 become even more speculative? 3 A. I think it becomes speculation, yes. Again, the 4 question is leaking or rupture? 5 Q. The question was rupture. 6 A. Again, I've -- I think I've stated that leaking is a 7 subcategory of rupture and -- and in order to leak, you must 8 have some element of rupture. 9 Q. So -- 10 MR. FRASURE: Wait, we're mixing -- I thought we had 11 this straight. So I can -- 12 MR. HIRSHMAN: I thought we did. So I can straighten 13 it out pretty quickly. 14 BY MR. HIRSHMAN: 15 Q. So, in other words, what we're saying is that at 3:50, 16 you are unable to state to a reasonable medical probability that 17 Wanda's liver was leaking and you're unable to state to a 18 reasonable probability that it was ruptured? 19 A. Right. 20 Q. Okay. 21 A. I think it's possible, but I can't be certain. 22 Q. Okay. Tell me you're not -- First of all, you're not 23 a neurologist? 24 A. No. 25 Q. No training in neurology? 67 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. No specialty training in neurology. 2 Q. Do you consider yourself an expert in -- Let me ask 3 you this: I'm not going to ask you whether you consider 4 yourself an expert. I'm going to ask you whether you have an 5 opinion that you feel you can give in this case regarding the 6 etiology and mechanism of Wanda's neurologic injury? 7 A. I think that most likely her neurologic injury was as 8 a result of hypotension and hypoperfusion of the brain. 9 MR. FRASURE: Hypo? 10 THE WITNESS: Hypotension. 11 MR. FRASURE: Okay. 12 THE WITNESS: And hypoperfusion. 13 BY MR. HIRSHMAN: 14 Q. Do you know Dr. Gemofski? 15 A. I do. 16 Q. I took Dr. Gemofski's deposition yesterday. 17 Dr. Gemofski indicated that it was his opinion that the 18 neurologic injury was the result of a combination of 19 hypotension, preceded by hypertension and that the two together 20 exacerbated the neurologic injuries that she sustained. Do 21 you -- do you disagree with that? 22 A. I don't know the basis of his opinion. I mean, I 23 clearly see the hypotension being operative here in the series 24 of events. 25 MR. FRASURE: Just make sure she gets it right. 68 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 THE WITNESS: I clearly see the hypotension being 2 operative here in the series of events. I'm not sure where he's 3 coming from regarding the role of the preceding hypertension. 4 BY MR. HIRSHMAN: 5 Q. You've -- Are you unfamiliar with the phenomenon of 6 hypertension -- Well, what happens to the brain in the face of 7 hypertension, how does it protect itself from hypertension such 8 as the hypertension that existed with Wanda? 9 A. You may get vasospasm. 10 Q. And what is the function of the vasospasm? 11 A. To reduce blood flow and reduce pressure within the 12 brain. 13 Q. All right. And it -- that occurs in order to protect 14 the brain, which is within a closed, confined space, from the 15 adverse effects that would be associated with a high level of 16 blood pressure within the skull, correct? 17 A. True. 18 Q. What happens when the blood pressure gives out to 19 that -- that's called auto regulation, by the way, is it not? 20 A. I think that is the term, yes. 21 Q. What happens when the blood pressure all of a sudden 22 and precipitously drops, does that vasospasm reverse itself 23 immediately in your opinion? 24 MR. FRASURE: Are you talking in general now or in 25 this case? 69 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MR. HIRSHMAN: We're talking in general. 2 THE WITNESS: In general, yeah, I think it can -- I 3 would attempt to be made to take place to reverse the 4 vasodilatory event. 5 Q. Do you know how long it takes for the body to reverse 6 itself? 7 A. I would imagine it's very quick. 8 Q. Do you feel that you're in a -- do you feel 9 comfortable and competent to render opinions on this issue? 10 MR. FRASURE: In this case, what's the issue though? 11 THE WITNESS: What's the question? 12 BY MR. HIRSHMAN: 13 Q. The issue -- 14 A. What's the specific question? 15 Q. My question is this, what -- do you have an opinion 16 that you feel competent to render on the affects of hypertension 17 preceding hypotension and the affects that it has on the brain? 18 A. I don't think so in the sense that I'm not sure what 19 the -- what the theory is there and as to how that exacerbated 20 or may have exacerbated the situation for Miss Wright. 21 Q. Would you defer to a neurologist on these issues? 22 A. I could defer to a number of people on these issues. 23 Q. Would one of them be a neurologist? 24 A. Depends upon the neurologist. I mean, some 25 neurologists concentrate in this area and some -- some don't 70 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 have much more knowledge than you or I about this. I wouldn't 2 defer to any neurologist about it, let me put it to you that 3 way. 4 Q. You wouldn't defer to just any neurologist? 5 A. Correct. Thank you. 6 Q. So you would defer to -- there certainly are others 7 with more -- more intense and specialized knowledge dealing with 8 this particular question that I'm asking you than you? 9 A. I think that's fair. I think there certainly is a 10 group of neurologists that deal with -- with issues regarding 11 cerebral blood flow more so than I do. 12 Q. Okay. 13 A. And there are may be others that deal with 14 hypertensive encephalopathy with respect to pregnancy more than 15 I have. 16 Q. Okay. 17 A. It's not an uncommon event. 18 Q. This much we know, that there is a phenomenon known as 19 overshooting when you're dealing with attempts in a pregnant 20 woman to reduce blood pressure, correct? 21 A. That's true. 22 Q. That's something you're aware of because you have to 23 reduce women's blood pressure in a pregnancy situation, correct? 24 A. Yes. 25 Q. When talking about overshooting, we're talking about a 71 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 desire not to reduce blood pressure too quickly for fear of 2 reducing the blood flow to the placenta and vital organs of the 3 mother, correct? 4 A. Yes. 5 Q. That's a phenomenon that you're familiar with? 6 A. Yes. 7 Q. Okay. And I've characterized it properly? 8 A. I think so. 9 Q. Okay. The women that you have treated for subcapsular 10 hematoma of the liver, how were they treated, what kinds of 11 interventions were utilized by you? 12 A. Well, in the first case, no specific treatment for the 13 hematoma. In the second case -- 14 Q. Which was the first? 15 A. I think I described the case of a woman with an intact 16 subcapsular hematoma. 17 Q. The first was intact. Okay. 18 A. Correct. 19 Q. Okay. What treatment was given? 20 A. Pardon? With respect to the hematoma? 21 Q. With respect to treating her for her condition as it 22 relates to hopefully getting her through what you understood to 23 be a -- if I understood correctly, when you noticed it, it had 24 already ruptured; is that right? 25 A. No. 72 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Okay. The first one had not? 2 A. Correct. 3 Q. Okay. And the first one is the one that was diagnosed 4 by imaging study? 5 A. Correct. 6 Q. Okay. And the treatment that was given to her upon 7 recognition of the subcapsular hematoma was what? 8 A. Delivery. 9 Q. By what means? 10 A. Vaginal. 11 Q. And what was done, if anything, to deal with the 12 potential problems that might arise from the existence of this 13 subcapsular hematoma? 14 A. Just close observation and supportive care. 15 Q. And what was the supportive care? 16 A. Essentially administration of IV fluids, blood 17 products as needed, and careful attention to the patient's vital 18 signs. 19 Q. What blood products were administered? 20 A. I don't remember specifically. 21 Q. The blood products would have been given in order to 22 attempt to address the source of the bleeding in the liver -- 23 A. I don't -- 24 Q. -- and systemically? 25 A. I don't recall specifically. I mean, it's a case of 73 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 many years ago and I -- you know, I could put it together in 2 retrospect and say probably related to falling hematocrit and 3 potentially mild coagulopathy, those types of issues. 4 Q. Those would be appropriate treatments for a woman in 5 that condition? 6 A. Sure. 7 Q. And, in fact, they succeeded in that this woman did 8 not go on to rupture and did not go on to die and did not go on 9 to sustain any significant neurologic injuries? 10 A. Right. 11 Q. Now, the second and third then were presented to you 12 as ruptures? 13 A. Yes. 14 Q. And presumably there was prompt intervention by you 15 and your colleagues to address the rupture of the liver? 16 A. True. 17 Q. And that prompt intervention included presumably 18 packing of the liver in order to address the bleed that was 19 going on in the liver? 20 A. I think in the second case for certain. 21 Q. And by "packing", we mean the insertion of surgical 22 sponges and in an attempt to stop the blood flow, correct? 23 A. True. To control any bleeding sites. 24 Q. And is this the second one, the one that died or that 25 survived? 74 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 MR. FRASURE: The third one. 2 THE WITNESS: No. The third one succumbed. 3 BY MR. HIRSHMAN: 4 Q. Okay. So as it relates to the second one, packing was 5 implemented and it succeeded in preventing -- in slowing down 6 the blood -- the bleed? 7 A. Yes, I believe so. 8 Q. And in the third, do you have a recollection of 9 whether that was done? 10 A. I think similar approach, but more extensive liver 11 hemorrhage unfortunately. 12 Q. Okay. In your opinion, did Wanda Wright have a 13 coagulopathy prior to the Cesarean section being performed? 14 A. I think technically she did in terms of she had 15 thrombocytopenia which is a form of a coagulopathy. 16 Q. All right. Do you have an opinion as to the timing of 17 the neurologic injury that Wanda sustained? 18 A. I don't think that her neurologic state, if I'm not 19 mistaken, was ever intact after the surgery per se. Initial 20 surgery, so sometime related to that. 21 Q. Do you know if it was before the surgery that she 22 sustained her -- 23 A. No. 24 Q. -- neurocompromising insult? 25 A. No. I think it was subsequent, but I can't give you 75 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 the exact time line on that. 2 Q. After she left the OR? 3 A. I can't be certain. 4 Q. I've asked a number of other people this question and 5 I'll ask you the question. Do you have an opinion as to whether 6 Wanda's death is the proximate cause -- Let's not use legal 7 words. 8 MR. FRASURE: You have it backwards. The proximate 9 result. 10 BY MR. HIRSHMAN: 11 Q. Okay. Do you have an opinion -- 12 A. Now I'm totally confused. 13 Q. We won't use -- we won't use this term. We'll just 14 talk in more comprehensible terms at least to begin with. Do 15 you have an opinion -- 16 A. I won't give a response in medical terms. 17 Q. Well, yes or no will do probably. 18 A. Good. 19 Q. Do you have an opinion as to whether Wanda's death is 20 the result of the events that occurred on March 17, 1998 during 21 her labor and delivery? 22 A. I think it's related to her HELLP Syndrome, her liver 23 rupture for certain ultimately. 24 Q. Okay. And that's your opinion to a reasonable medical 25 probability? 76 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A. True. 2 Q. You're licensed in Ohio? 3 A. Yes. 4 Q. And what percentage of your practice constitutes a 5 practice with -- actual clinical practice? 6 A. I think about 80 percent of my time roughly is spent 7 in clinical medicine. 8 Q. Okay. 9 MR. HIRSHMAN: Give me a moment here to look at your 10 letter. I think I'm about done. 11 (Pause.) 12 BY MR. HIRSHMAN: 13 Q. I'm almost done. What was the condition of Wanda's 14 cervix? 15 MR. FRASURE: Of her cervix? I'm sorry. 16 THE WITNESS: Initially on presentation? 17 BY MR. HIRSHMAN: 18 Q. Well, throughout this hospitalization. 19 MR. FRASURE: Throughout the labor? 20 BY MR. HIRSHMAN: 21 Q. Throughout labor. 22 A. I think initially it was closed, may have been a 23 little bit effaced. I can't recall. 24 Q. Well, what I see is this. 25 A. Sure. 77 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. Tell me if there's anything else. I see a closed 2 surface documented with 60 percent effacement and minus 2 3 station. 4 A. Yes. 5 Q. Was she ready to deliver with or -- 6 MR. FRASURE: With or without the -- Go ahead. 7 THE WITNESS: I think your question is was she 8 inducible or should she have been induced. I mean, no one is 9 ready to deliver until they're completely dilated. 10 BY MR. HIRSHMAN: 11 Q. All right. 12 A. Fair. 13 Q. All right. 14 A. So the question is the wisdom of induction in this 15 setting. In this case, I think it was a good move. I think it 16 was the right move. And I think you have a multiparous patient 17 who has got severe preeclampsia, HELLP Syndrome. The last thing 18 you want to be doing is to be going through the operating room 19 opening that patient if you have any reasonable chance of 20 getting her delivered vaginally. And she had some points for 21 getting delivered vaginally in that she was a grand mal tip and 22 it certainly, you know, was worth a shot if she could be 23 stabilized. I think that's pretty much the standard of care 24 would be to try to stabilize the patient, and if you could get 25 them delivered vaginally, vaginal delivery would be preferable. 78 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 Q. All right. 2 A. I mean, there are some people who put their hands up 3 when they see HELLP Syndrome and want to go run and do a 4 Cesarean section, but generally those are people who haven't 5 managed a lot of HELLP Syndrome. 6 Q. Once a diagnosis is made of subcapsular hematoma, your 7 approach would presumably change? 8 A. Intact or bleeding? 9 Q. Let's say it's intact. 10 A. Well, if it's intact, you try to get a vaginal 11 delivery if you could. 12 Q. Okay. You have no concerns about the amount of 13 pressure that a labor would -- the amount of pressure and 14 potential trauma that a course of labor would have on the liver? 15 A. I think it's a judgment call. I think you have a 16 concern, but I think if you can affect vaginal delivery in a 17 reasonable period of time and -- and the mother is 18 hemodynamically stable, that would be the way to go. 19 Q. And what constitutes hemodynamic stability? 20 A. Absence of hypotension essentially is what we're 21 speaking of. 22 MR. HIRSHMAN: No more questions. 23 MR. FRASURE: Mr. Spisak. 24 MR. SPISECK: I have no questions. Thank you, Doctor. 25 MR. FRASURE: Okay. We'll read. 79 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 (Signature not waived.) 2 - - - 3 (Thereupon, the deposition was concluded at 7:51 4 o'clock p.m. on Wednesday, November 22, 2000.) 5 - - - 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 80 MC GINNIS & ASSOCIATES, INC. COLUMBUS, OHIO 614.431.1344 800.498.2451 www.mcginniscourtreporters.com 1 A F F I D A V I T 2 - - - 3 STATE OF ___________________, ) ) SS: 4 COUNTY OF ___________________, ) 5 Mark B. Landon, M.D., having been duly placed under 6 oath, deposes and says that: 7 I have read the transcript of my deposition taken on 8 Wednesday, November 22, 2000 and made all necessary changes 9 and/or corrections as noted on the attached correction sheet, if 10 any. 11 12 ________________________________ 13 Mark B. Landon, M.D. 14 Placed under oath before me and subscribed in my 15 presence this ______ day of __________________, 20___. 16 17 ________________________________ Notary Public 18 My Commission Expires: ___________________________. 19 - - - 20 21 22 23 24 25