1 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 TONI L. BIANCHI, Executrix, etc., et al., 4 Plaintiffs, 5 JUDGE BOYKO -vs- CASE NO. 410037 6 KAISER FOUNDATION HEALTH 7 PLAN OF OHIO, et al., 8 Defendants. 9 - - - - 10 Telephone deposition of ROBERT A. MULLIKEN, 11 M.D., taken as if upon cross-examination before 12 Judith A. Gage, a Registered Merit and Certified 13 Realtime Reporter and Notary Public within and 14 for the State of Ohio, at the offices of Bonezzi, 15 Switzer, Murphy & Polito, 1400 Leader Building, 16 Cleveland, Ohio, at 5:30 p.m. on Thursday, 17 February 15, 2001, pursuant to notice and/or 18 stipulations of counsel, on behalf of the 19 Defendant in this cause. 20 - - - - 21 MEHLER & HAGESTROM Court Reporters 22 CLEVELAND AKRON 23 1750 Midland Building 1015 Key Building Cleveland, Ohio 44115 Akron, Ohio 44308 24 216.621.4984 330.535.7300 FAX 621.0050 FAX 535.0050 25 800.822.0650 800.562.7100 2 1 APPEARANCES: 2 Tobias Hirshman, Esq. (Telephonically) 3 Mark Ruf, Esq. (Telephonically) Linton & Hirshman 4 700 West St. Clair Avenue Hoyt Block, Suite 300 5 Cleveland, Ohio 44113-1230 (216) 771-5800, 6 On behalf of the Plaintiff; 7 8 Susan Reinker, Esq. Bonezzi, Switzer, Murphy & Polito 9 1400 Leader Building Cleveland, Ohio 44114 10 (216) 875-2767, 11 On behalf of the Defendants. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3 1 - - - - 2 (Thereupon, Defendant's Exhibit A, 3 Curriculum Vitae, was marked for purposes 4 of identification.) 5 - - - - 6 MS. REINKER: Are we ready? 7 Doctor, can you hear me all right? 8 THE WITNESS: Yes, I hear you 9 fine. 10 MS. REINKER: Mark, the court 11 reporter is here with me, she is from 12 Mehler, Judy Gage. Judy, why don't you go 13 ahead and swear the doctor in. 14 Mark, I presume that you are 15 willing to waive the fact that the notary 16 public and the court reporter is here with 17 me rather than being in Chicago with the 18 doctor? 19 MR. RUF: Yes, I am. We're 20 willing to agree to the manner in which 21 this is being taken. 22 ROBERT A. MULLIKEN, M.D., of lawful age, 23 called by the Defendant for the purpose of 24 cross-examination, as provided by the Rules of 25 Civil Procedure, being by me first duly sworn, as 4 1 hereinafter certified, deposed and said as 2 follows: 3 CROSS-EXAMINATION OF ROBERT A. MULLIKEN, M.D. 4 BY MS. REINKER: 5 Q. Doctor, I just introduced myself to you a few 6 moments ago. My name is Susan Reinker and I 7 represent Dr. Haluska and the Kaiser entities 8 that have been sued in this case. 9 I will be asking you some questions today. 10 If you don't understand a question or if you 11 can't hear it or if it is cut off on the 12 telephone, please be sure to let me know that 13 before you answer because of course I'm going to 14 be relying on the answers you give today when 15 this case goes to trial. Can we have that 16 agreement between us? 17 A. Yes, I understand. 18 Q. Okay. Would you state your full name, please, 19 sir, for the record? 20 A. It's Robert Mulliken. M-u-l-l-i-k-e-n. 21 Q. Do you have a middle name? 22 A. Alan, A-l-a-n. 23 Q. Have you ever gone by any other names, or is that 24 it? 25 A. I have not. 5 1 Q. Your date of birth is September 7 of 1958, is 2 that correct? 3 A. That is correct. 4 Q. Which would make you 42 years old? 5 A. Correct. 6 Q. What is your Social Security number, please? 7 A. 350-46-1779. 8 Q. Is that the number you would like us to use when 9 I write you a check for your testimony today? 10 A. That would be correct. 11 Q. Okay. Who is your current employer? 12 A. University of Chicago. 13 Q. I gather you're with an emergency group, an ER 14 group at that institution? 15 A. We are the section of emergency medicine within 16 the Department of Medicine and we're staff 17 physicians at the University Hospital. 18 Q. So there is no independent ER group, you are paid 19 directly by the University? 20 A. I am. 21 Q. How many Emergency Room physicians are in that 22 group? 23 A. Roughly 12. 24 Q. The University of Chicago is located actually in 25 Chicago? 6 1 A. It is Hyde Park, which is a subsection of 2 Chicago. 3 Q. Is it still Cook County? 4 A. It is Cook County. 5 Q. How many emergency rooms does the University of 6 Chicago have? 7 A. There is an adult and a pediatric emergency 8 department. 9 Q. What is the name of the hospital facility in 10 which the ER is located? 11 A. It's the Bernard Mitchell Hospital. 12 Q. And is that one of a number of hospitals 13 affiliated with the University? 14 A. There are a number of buildings on the hospital 15 complex that have different names, but it is one 16 medical center. 17 Q. I guess I'm a little surprised that there are 18 only twelve ER physicians. I sort of assumed at 19 a big teaching institution there would be 30 ER 20 physicians. Is this a somewhat small unit or is 21 it only for certain types of patients or how does 22 it work? 23 A. The section I'm talking about is adult emergency 24 medicine. We cover just the adult side. 25 Q. Do you take any ER patients from the local 7 1 community who might happen to walk in? 2 A. We take anybody who presents to the front door. 3 Q. Where are you located now at the time of this 4 deposition? 5 A. My office. 6 Q. At the University of Chicago? 7 A. Correct. 8 Q. Is anyone with you in your office? 9 A. No. 10 Q. Do you have with you today all of the records, 11 correspondence, notes, everything in your 12 possession relating to this lawsuit? 13 A. Everything that I have been provided, which I 14 believe is complete in the case I have. 15 Q. It is all there in front of you today as you are 16 being deposed? 17 A. Yes. 18 Q. We have your curriculum vitae, which I have 19 marked as Exhibit A. This was provided to us by 20 Mr. Ruf or Mr. Hirshman. I think it is six pages 21 long, maybe. 22 A. That would seem correct. 23 Q. Hold on one second here. 24 Yes. Five pages and a little bit on the top 25 of the sixth. Is that your most current C.V.? 8 1 A. What's the revision date? 2 Q. Where would I look for that? 3 A. On the last page, bottom left hand corner. 4 Q. Revised July, 1999. 5 A. My most current one with minor revisions is 6 January, '01. And it does not vary substantially 7 from the one that you have. 8 Q. Just so we're up to date, would you send a copy 9 of that to Mr. Ruf so I can have it before the 10 trial? 11 A. I will. 12 Q. Do you currently hold the position of medical 13 director in your department? 14 A. Yes. 15 Q. Is that -- are you the only one to occupy that 16 position or is that a shared job title? 17 A. No. I am the only occupant of that title, and 18 have been for the past eleven years. 19 Q. So you finished your training about eleven years 20 ago, correct, 1990? 21 A. Exactly. 22 Q. So you immediately stepped into the position of 23 medical director? 24 A. For six months I was the director of clinical 25 operations, and then promoted to medical director 9 1 of the ER. 2 Q. Did they just start their ER back then? 3 A. No. 4 Q. Okay. But there was no one senior to you who 5 would prefer to be the medical director instead 6 of this young fellow coming out of his residency? 7 A. At the time I had additional training in internal 8 medicine, so I had three extra years on what 9 would have been the average person coming out of 10 training. 11 Q. Why did you choose not to go into a practice of 12 internal medicine? 13 A. As a matter of fact, I was chief resident and had 14 a lot of administrative responsibilities during 15 my residency. I chose an academic career in 16 which to teach, do some research, and supervise 17 the training of residents in the training program 18 of emergency medicine. 19 Q. And you chose not to pursue academic medicine in 20 internal medicine but chose to pursue it in 21 emergency medicine instead? 22 A. My choice to train in internal medicine was also 23 founded in subsequent training in emergency 24 medicine without interruption and without 25 consideration for private practice. 10 1 Q. So you never intended to go into the private 2 practice of internal medicine? 3 A. I did not. 4 Q. If you will look at your C.V. there, do you have 5 a copy of it with you? 6 A. I do. 7 Q. On the third, what I have as the third page, it 8 says 1990-present, the University of Chicago 9 emergency medicine residency program, and then 10 there is a list. 11 A. Yes. 12 Q. Do you see that? What is that list? 13 A. Actually, that comes under lectures that I give 14 for the residency program. And it's the prior 15 page before, there is a heading of lectures, 16 starting out with physical diagnosis 17 instructor -- 18 Q. I see. Okay. So these are all the lecture 19 topics that you have given for the residents in 20 your own program? 21 A. Yes. 22 Q. Do you have any written materials that go along 23 with any of these lecture topics? 24 A. Not in any official format, no. 25 Q. So when you speak to the residents on the 11 1 evaluation of chest pain, the third item down on 2 the list, you would not have a handout or a 3 syllabus or a checklist you would give to them? 4 A. That lecture actually is given in many formats. 5 It includes electrocardiograms and clinical case 6 scenarios and slide presentations. 7 Q. And you don't have any written materials at all 8 that you would give to the residents kind of 9 organizing all those materials you just 10 mentioned? 11 A. Probably not. It would mostly be in slides. I 12 also give a lecture on the evaluation of cardiac 13 events to the medical students in the Pritzker 14 Medical School. 15 Q. Now, what is the Pritzker Medical School? 16 A. University of Chicago medical school. The name 17 Pritzker is a benefactor. 18 Q. So that's the name of the entire medical school, 19 it's not a subdivision of the medical school? 20 A. No, it's the entire medical school. 21 Q. The lecture, now, when you say lectures, 1993 to 22 the present that you lecture on physical 23 diagnosis, you're a physical diagnosis 24 instructor? 25 A. Yes. 12 1 Q. Does that mean that you teach one course every 2 year since 1993 on physical diagnosis? 3 A. Every year since 1993 I am assigned four medical 4 students in which a roughly two semester course 5 is on the teaching of history and physical, 6 diagnosis. Instructor over each year. 7 Q. So the four students come work with you in the 8 Emergency Room or do you teach a lecture with 9 them on some regular basis at the school? 10 A. I give an occasional lecture to the Pritzker 11 medical school and the physical diagnosis course 12 is actually critiquing and evaluating their case 13 presentations of patients. It also involves 14 supervising physical examinations. That's 15 usually done in the emergency medical department. 16 Q. So the cases they have seen, those are students 17 that have seen these cases in the ER and then 18 present them to you? 19 A. They generally find them on the internal medical 20 floor and we generally supplement that with 21 hands-on visiting of patients in the emergency 22 department. 23 Q. Do you go with these four students to the 24 internal medicine floor and yourself evaluate the 25 patients they are going to present to you? 13 1 A. That supervision and assignment of patients is 2 done in conjunction with the fourth year medical 3 students and internal medicine residents. 4 Q. I guess I'm just confused as to how you call this 5 a lecture. 6 A. Which? 7 Q. Working with these four students in physical, as 8 a physical diagnosis instructor. 9 A. Okay. It probably would not officially be a 10 lecture. It would be an academic teaching 11 endeavor that could have been titled different. 12 Q. So you are on the faculty of the Pritzker medical 13 school? 14 A. I am on faculty of the University of Chicago 15 biologic science division, but probably not 16 officially a faculty member of Pritzker medical 17 school. 18 Q. Do you teach any classroom lectures on a regular 19 basis? 20 A. I teach one classroom lecture on a regular basis 21 to Pritzker medical school on the evaluation of 22 people with potential heart attacks. 23 Q. And that's a recurring class that meets every 24 Wednesday at 3:00 p.m. or something? 25 A. No. That's a once a year lecture out of a series 14 1 of about 15 or 20 that are given to second year 2 medical students who elect to take a course 3 called introduction to emergency medicine. 4 Q. Okay. So other than that one lecture every year, 5 do you give any other in-classroom teaching on a 6 regular basis at any medical school? 7 A. Not at a medical school, but I do or have done 8 for three or four years in a row a written boards 9 review course on cardiology. 10 Q. And where is that conducted? 11 A. That's usually a 45 minute lecture once a year to 12 roughly 500 participants in a downtown hotel 13 location in preparation for their board 14 examination. 15 Q. And I presume some group or agency puts on these 16 lectures, it's like a refresher course? 17 A. Correct. 18 Q. And you're compensated by that group? 19 A. Yes. 20 Q. What's the name of that group who puts on the 21 lectures? 22 A. The Illinois College of Emergency Physicians. 23 Q. Does that, those two lectures which you do on a 24 yearly basis, does that comprise your classroom 25 teaching? 15 1 A. I give roughly two or three lectures a year to 2 our emergency medicine residency program in which 3 you have, under "'99 to present" is a compilation 4 of maybe 30 of those over time. 5 Q. What you're talking about is what I started out 6 with on page three, this list? 7 A. Yes. 8 Q. And that's 1990 to present. 9 A. Right. 10 Q. Okay. Do you have any subspecialty interest or 11 training in geriatric medicine? 12 A. Not any except that it is a prominent field of -- 13 prominent subspecialty of internal medicine. 14 Q. I notice most of your publications seem to have 15 something to do with the treatment of elder 16 patients. 17 A. It has to do with a research group that I was 18 involved with that were two internal medicine, 19 general internists with public health degrees who 20 were interested in emergency department elderly 21 patient visits, and included the section chief of 22 internal medicine, who was a geriatrician, and a 23 separate geriatric -- there was the chief of 24 general internal medicine, who was one of the 25 project sponsors, and she is a geriatrician, and 16 1 also another geriatrician involved. 2 It was an internal medicine group heavily 3 influenced or weighted towards geriatrics and 4 public health that studied emergency department 5 patients. 6 Q. And this was a research project that concluded 7 sometime before 1997? 8 A. Around then. 9 Q. And you have not been involved in this kind of a 10 geriatric project since? We missed your answer 11 if you gave one. 12 A. No. 13 Q. If you look at page five of your C.V., you have a 14 section entitled hospital activities. 15 A. Yes. 16 Q. Now, is that a description of your ongoing job 17 duties? 18 A. Yes. 19 Q. Are these the kinds of things you still do 20 routinely as part of your job, or were these 21 things listed here one-time projects? 22 A. No. They are ongoing job descriptions. 23 Q. Are you involved at all in patient care? 24 A. Roughly 60 percent of my time is patient care. 25 Q. And how -- where and how do you do your patient 17 1 care? 2 A. I attend in the adult emergency department 3 roughly 28 hours a week. 4 Q. 28 hours a week? Do you work twelve hour shifts 5 or how is it set up with your emergency group? 6 A. It's eight hour shifts and it's a number of 7 shifts per month. 8 Q. Okay. So you work roughly three and a half 9 shifts a week? 10 A. Correct. 11 Q. How many residents are involved in your program? 12 A. 36. 13 Q. Is it a three year residency? 14 A. Yes. 15 Q. So twelve are admitted each year? 16 A. Yes. 17 Q. And they are trained by all of the physicians in 18 your group, I presume. 19 A. Correct. 20 Q. Do you have -- when you are working your eight 21 hour shifts, again, two and a half per week, do 22 you generally work night shift or evening? How 23 is it set up? What hours of the day? 24 A. A mixture of nights, evenings, days, and 25 weekends. 18 1 Q. But it's just eight hours, you don't do any 2 twelve hour shifts? 3 A. Very occasionally, on holidays. 4 Q. When you -- do any of the teaching, lectures, 5 things like that that you present involve any 6 books? Do you have any books or journal articles 7 that you provide? 8 A. My lectures are usually reference to textbooks 9 and the related specialties which the topic 10 involved. I don't in general pass out written 11 material. 12 Q. When you teach your course on cardiology, your 13 lecture on cardiology, what books do you refer to 14 for that lecture? 15 A. The lecture on cardiology to the medical school 16 has a handout and it's a mixture of emergency 17 medicine textbooks and internal medicine 18 textbooks. 19 Q. So you do have that handout available? 20 A. I have an outline for the lecture. 21 Q. Could you also send that to Mr. Ruf? I would 22 like a copy of that outline as well. 23 How did you happen to get involved in this -- 24 you will sent that to Mr. Ruf, correct, that copy 25 of that outline? 19 1 A. Yes. Let me write that down. 2 Q. That is two things you are going to send. 3 MR. HIRSHMAN: We'll keep tabs on 4 that. 5 MS. REINKER: Mr. Hirshman has 6 joined us. 7 MR. HIRSHMAN: Mr. Hirshman has 8 joined you. 9 Q. How did you happen to get involved in this piece 10 of litigation we're here about? 11 MR. HIRSHMAN: Pardon me? 12 MS. REINKER: Excuse me? 13 MR. HIRSHMAN: I thought you were 14 talking to me. 15 MS. REINKER: If you care to 16 answer that that's okay, but I was 17 addressing that to the doctor. 18 MR. HIRSHMAN: I didn't hear the 19 question. 20 Q. The question was how did you happen to get 21 involved in this lawsuit? 22 A. I was referred the case. 23 Q. How? 24 A. A colleague of mine asked me if I would review 25 the case. 20 1 Q. And who was the colleague? 2 A. It's a Dr. Gordon. 3 Q. Is Dr. Gordon in your group? 4 A. He was a resident in training in my class. 5 Q. Where is he now? 6 A. Cleveland, Ohio. 7 Q. Do you know where he is working here in 8 Cleveland? 9 A. I do not know, no. 10 Q. Did he call you and ask you to look at this case? 11 A. He either called or sent me a letter. 12 Q. Do you happen to have that letter with you today? 13 A. I do not. 14 Q. Do you know how Dr. Gordon got involved in this? 15 A. I do not. 16 Q. Do you know why he asked you to get involved? 17 A. I occasionally review cases for attorneys that 18 have asked him to find expert witnesses. 19 Q. You mean you have reviewed cases for attorneys 20 who have asked Dr. Gordon to look at cases? 21 A. Dr. Gordon refers expert witnesses. 22 Q. So this is not the only case you have looked at 23 at the request of Dr. Gordon. 24 A. I look at -- I have looked at a couple of cases 25 for Dr. Gordon. 21 1 Q. What is his first name? 2 A. Ronald. 3 Q. Do you know if Dr. Gordon is still practicing 4 medicine? 5 A. I believe he is, yes. 6 Q. Does he work with any kind of an Emergency Room 7 group that you are aware of? 8 A. I believe he is in clinical practice in 9 Cleveland. 10 Q. But you don't know where or how? 11 A. I do not, no. 12 Q. Do you know if Dr. Gordon has any kind of a 13 corporation or business entity that finds doctors 14 to review cases for lawyers? 15 A. I believe he does, yes. 16 Q. What's the name of that group? 17 A. I think it's R. S. Gordon Incorporated. 18 Q. How many cases have you looked at for R. S. 19 Gordon Incorporated? 20 A. Between five and ten. 21 Q. Now, so I understand this correctly, the initial 22 contact was completely with Dr. Gordon, it was 23 not from Mr. Hirshman or Mr. Ruf? 24 A. That would be correct. 25 Q. Do the materials in front of you include anything 22 1 at all that you received from Dr. Gordon? 2 A. They do not. 3 Q. Do you recall what Dr. Gordon -- did Dr. Gordon 4 send you anything to review or did he send you a 5 summary of the case, or how did that happen? 6 A. My recollection is that Dr. Gordon asked me if I 7 would be willing to review a case and I would 8 have responded -- with a description, and I would 9 have responded yes, and then the materials would 10 have been forwarded by Mr. Ruf's office. 11 Q. Do you remember anything at all that Dr. Gordon 12 told you about this case at the point in time you 13 agreed to review it? 14 A. Probably no specific details. No specific 15 clinical details we elaborated on. 16 Q. Now, you prepared some letters in this case which 17 we call reports. 18 A. I did. 19 Q. Do you have those in front of you? 20 A. I do. 21 Q. How many do you have there? 22 A. I should have two. 23 Q. I'm looking at two reports. One of them is 24 directed to Mr. Mark Ruf and is dated October 26, 25 2000. The other is addressed to Mr. Hirshman and 23 1 Mr. Robert Linton with no date on it. Do you 2 have those two reports in front of you? 3 A. I do. 4 Q. Do you recall which one came first? 5 A. The one that is not dated is roughly March of 6 2000. 7 Q. I'm going to have that one, the one that's 8 addressed to Mr. Hirshman and Mr. Linton marked 9 as Exhibit B since that was the first report, and 10 we'll have the October 26 one marked as 11 Exhibit C. 12 - - - - 13 (Thereupon, Defendant's Exhibit B, 14 Report of Robert Mulliken, M.D., undated and 15 Defendant's Exhibit C, Report of Robert Mulliken, 16 M.D. dated 10/26/99 were marked for purposes of 17 identification.) 18 - - - - 19 Q. Did you have any other written documents that you 20 sent to Dr. Gordon or to Mr. Ruf or to 21 Mr. Hirshman or Mr. Linton or anybody else 22 involved in this case? 23 A. I do not. 24 Q. No other prepared reports? 25 A. No. 24 1 Q. Now, the materials you have in front of you, do 2 they include any correspondence that you received 3 from anybody? 4 A. They do not. 5 Q. Did you get any letters from anybody in this 6 case? 7 A. Actually, I might have to take that back. The 8 original medical records would have come with a 9 letter describing the case from either 10 Mr. Hirshman, Ruf or Linton's office to preface 11 the materials that I had received. 12 Q. Do you have that correspondence with you? 13 A. I have a correspondence, yes. 14 Q. Okay. Now, is that the only letter you have ever 15 received from the Plaintiff's lawyers? 16 A. I had received several depositions in follow-up, 17 and they would just note the name of the 18 deposition and who had sent it to me. 19 Q. What I would like you to do is to take all the 20 letters you received in this case and set them 21 aside, put them in a little pile next to you 22 there. 23 Now, what is the date of the first 24 correspondence that you received? 25 A. The first correspondence I believe is March 9, 25 1 2000. 2 Q. March 9, 2000? And who was that from? 3 A. Mr. Hirshman. 4 Q. How long of a letter is that? 5 A. Page and a half. 6 Q. Does that letter summarize anything about the 7 facts of this case? 8 A. It does. 9 Q. Could you read that letter for me, please? 10 MR. HIRSHMAN: He is not reading 11 that letter. 12 MS. REINKER: Why is he not 13 reading that letter? 14 MR. HIRSHMAN: Because he's not 15 and what we will do is I will take a look 16 at it and I will decide whether or not you 17 are entitled to it. 18 Q. Doctor, did you ever read that letter? 19 A. I read the letter. 20 Q. Did you read it when you got it? 21 A. Shortly thereafter. 22 Q. Okay. And I presume that you considered what 23 that letter said before you sat down to review 24 the case. 25 A. I read the letter and then read the records. 26 1 Q. Now, did that letter enclose any records? 2 A. It would have enclosed the emergency department 3 records in this case. 4 Q. Does the letter contain any listing, like 5 "enclosed please find the following"? 6 A. The letter came with a binder and an index that 7 enclosed certain documents. 8 Q. Okay. Now, I would like to know, do you still 9 have that binder there? 10 A. I do. 11 Q. Okay. And I would like you to read what it is 12 you reviewed. What were you sent to review with 13 that letter? 14 A. Actually, what is listed on one of my letters is 15 all of the records that I reviewed for this case, 16 and actually the two separate letters list out 17 all the various records, Kaiser emergency 18 department and depositions. 19 Q. Okay. So I'm looking at what we have marked as 20 Exhibit B, which is your first letter, the one 21 you said was sometime in March of 2000 -- 22 A. Yes. 23 Q. Now, according to that, and just so I can make my 24 own little list here, you got the Parma -- the 25 Kaiser output electronic and the EDCDU records? 27 1 A. Yes. 2 Q. The autopsy report, correct? 3 A. Yes. 4 Q. And then a series of depositions. 5 A. Yes. 6 Q. And the chest x-rays. 7 A. Yes. 8 Q. Do you still have the chest x-rays there with 9 you? 10 A. Not with me here. 11 Q. Where are they? 12 A. At my house. 13 Q. Do you recall what dates were -- what dates of 14 chest x-rays you looked at? 15 A. I recall a single chest x-ray from December 7, 16 1997. 17 Q. Okay. Did you read every one of these 18 depositions in toto? 19 A. I did. 20 Q. Now, at the time you prepared your first report, 21 did you review anything else other than the 22 things listed in that report? 23 A. I did not. 24 Q. Did you do any medical research? I'm sorry. If 25 you answered, again, we missed it. 28 1 A. No. I believe I may have reviewed a chapter in 2 Cecil or Brownweld's text on aortic dissection. 3 Q. Do you have copies of any literature there with 4 you that you might have looked at? 5 A. It would have been the most recent text of 6 Cecil's Medicine and Brownweld's Heart Disease. 7 Q. And you believe you looked at both of them? 8 A. I think I did. 9 Q. Did you look at any other literature before 10 preparing the first report, Exhibit B? 11 A. No. 12 Q. Did you discuss the case with anybody before you 13 prepared that report? 14 A. Mr. Ruf. 15 Q. Okay. Anybody else? 16 A. I would imagine -- actually, Mr. Ruf or 17 Mr. Hirshman. 18 Q. Did you ever discuss the case with Dr. Gordon? 19 A. I did not. 20 Q. Any of your colleagues there at the University of 21 Chicago? 22 A. I did not. 23 Q. Do you happen to know any of the persons involved 24 in this lawsuit? 25 A. I do not. 29 1 Q. Do you know -- you don't know Dr. Haluska, I 2 presume? 3 A. I do not. 4 Q. Or any of the other doctors, Dr. Gajdowski, Dr. 5 Kaforey? 6 A. Not a single person involved in this case have I 7 met. 8 Q. Have you reviewed anything else before or did you 9 review anything else before preparing your second 10 report, the one dated October 26? 11 A. That lists the depositions I reviewed and the 12 Kaiser encounter system notes. 13 Q. Is everything you reviewed in this case listed in 14 these two letters? 15 A. It is. 16 Q. So then you have never seen any of the expert 17 reports? 18 A. I have not. 19 Q. Either the reports prepared -- the other reports 20 prepared on behalf of the plaintiff, or the 21 reports that we have submitted on behalf of the 22 Defendants. 23 A. I have not seen them. 24 Q. Okay. Do you even know the names of any of the 25 expert witnesses? 30 1 A. I do not. 2 Q. Now, other than the letter of March 9, how many 3 other letters do you have set aside there that 4 you have received from plaintiff's counsel? 5 A. I only seem to have one other letter. 6 Q. And what's the date of that? 7 A. October 16. 8 Q. 2000? 9 A. Yes. 10 Q. And what -- how long is that letter? 11 A. Three sentences. 12 Q. Did that enclose additional materials? 13 A. It did. 14 Q. What did it enclose? 15 A. Additional depositions. 16 Q. Okay. Which depos were sent at that time? 17 A. Retzer, I actually think Wilson, and Abernathy. 18 Q. Okay. Now, at any point did you receive any 19 summaries or chronologies prepared by anyone 20 other than yourself to review? 21 A. No. 22 Q. Did you look at the records, the Kaiser records 23 before the Emergency Room visit of December 7, 24 '97? 25 A. The first record I probably reviewed was the 31 1 emergency department medical electronic record. 2 Q. So you didn't go back and look at the prior 3 outpatient records? 4 A. Not prior to reading that. 5 Q. Have you ever gone back and reviewed the 6 outpatient records? 7 A. I have. 8 Q. I'm sorry, what was the answer? 9 A. Yes, I have. 10 Q. Did you prepare any notes when you reviewed any 11 of these materials? 12 A. No. 13 Q. When you read all these documents, did you make 14 any notes on the documents themselves? 15 A. I may have highlighted areas of the document. 16 Q. But you have no handwritten notes, computer 17 generated notes, nothing at all of that kind? 18 A. None whatsoever. 19 Q. When is the last time you looked -- read all 20 these depositions and looked through everything? 21 A. This weekend. 22 Q. And did you make any notes or outlines or 23 anything this weekend? 24 A. I did not. 25 Q. Did you happen to know Mr. Ruf, Mr. Hirshman or 32 1 Mr. Linton before this lawsuit? 2 A. I did not. 3 Q. You said you have looked at five or ten cases for 4 Dr. Gordon. Were those all Emergency Room cases? 5 A. They were. 6 Q. Did they all originate here in the Cleveland 7 area? 8 A. I'm not sure, but probably the majority did. 9 Q. Have you ever testified in Cleveland, come here 10 to testify? 11 A. I have not. 12 Q. In the five or ten cases you looked at, have you 13 agreed to be an expert in any of them other than 14 this one? 15 A. I have given opinions on all of them and have 16 submitted written reports on a couple of them. 17 Q. Do you recall any of the names of the other 18 lawyers with whom you are working here in 19 Cleveland? 20 A. I do not. 21 Q. You have met some other lawyers, I presume, in 22 Cleveland, other than Mr. Ruf and Mr. Hirshman? 23 A. Actually, Peter Weinberger, if I remember. 24 Q. Have you given a deposition in the case in which 25 Mr. Weinberger was involved? 33 1 A. I did not. 2 Q. Is that something that's still open, pending? 3 A. Settled. 4 Q. You did write a report, though? We missed your 5 answer if you gave one. 6 A. I believe I did. 7 Q. Any other letters or reports you have written, 8 any lawyers' names that you remember, in Ohio? 9 A. No. 10 Q. Have you given any depositions in any of the 11 cases in Ohio? 12 A. None. 13 Q. And you have never come to Cleveland to testify 14 or anywhere else in Ohio? 15 A. No. 16 Q. What are your fees for reviewing a case? 17 A. I'm paid for my time. 18 Q. And what do you charge for your time? 19 A. About $200 an hour. 20 Q. Does that go to you or does that go to 21 Mr. Gordon? 22 A. That is my fee. 23 Q. How much do you charge for your deposition time? 24 A. $400 an hour. 25 Q. And how about trial time? 34 1 A. The same. 2 Q. Do you have any idea how much you have been paid 3 to date in this case? 4 A. $2200. 5 Q. Other than reviewing the cases for Dr. Gordon's 6 group, have you looked at any other cases -- have 7 you been retained to look at any other cases, 8 medical malpractice cases? 9 A. I have. 10 Q. Do you do that for any other service other than 11 Dr. Gordon's service? 12 A. I do not. 13 Q. How do you get the other cases? 14 A. Personal referrals, or collegial referrals. 15 Q. Now you started in practice in roughly 1990. Did 16 you begin reviewing cases right away as well? 17 A. Probably in the early 1990s. 18 Q. Roughly how many cases do you look at each year? 19 A. Somewhere between two and ten. 20 Q. And how many depositions do you give each year? 21 A. I rarely give depositions. Only maybe one or two 22 in the entire period. 23 Q. This is only the second deposition you have ever 24 given? 25 A. I have given depositions for other cases 35 1 involving medical matters during my training and 2 practice. I have given only a couple of expert 3 witness depositions. 4 Q. Of the cases that you look at, the two to ten a 5 year, roughly how many are on behalf of the 6 plaintiff and how many on behalf of the 7 defendant? 8 A. I have no idea. 9 Q. You don't keep track of that at all? 10 A. I do not. 11 Q. Now, the cases Mr. Gordon, Dr. Gordon sends to 12 you are probably all on behalf of the patient, 13 aren't they? 14 A. I would think the vast majority have been, yes. 15 Q. Is that true of the cases you get from personal 16 referral as well? 17 A. I have been asked to defend doctors and 18 hospitals. 19 Q. Roughly how many times have you been -- have you 20 written a report on behalf of a doctor or a 21 hospital? 22 A. I'm going to guess that it's near 50/50, but 23 maybe slightly leaning more towards the patient 24 side. 25 Q. How many depositions, how many cases did you 36 1 review last year, the year 2000? Do you 2 remember? 3 A. Probably six or seven. 4 Q. And how many of those were on behalf of the 5 doctor? 6 A. Probably four, five. 7 Q. Have you ever testified on behalf of a physician? 8 A. I've given courtroom testimony, never as an 9 expert. 10 Q. Have you ever written a report on behalf of a 11 doctor? 12 A. I think I have. I don't recall particularly. 13 Q. Do you recall if any of them were in Ohio? 14 A. I don't think so. 15 Q. And again, you have never testified in Court, 16 correct? 17 A. Not as an expert, but in related matters to 18 medical cases within hospitals I have worked. 19 Q. Have you yourself ever been sued as a defendant? 20 MR. RUF: Objection. 21 Q. You can answer, doctor. 22 A. Roughly 14 years ago I was named briefly and 23 dismissed from a case. 24 Q. That's the only time? 25 A. Only time. 37 1 Q. And you have been in Cook County all these years? 2 A. I have. 3 Q. I would suspect that there have been lawsuits 4 filed against your Emergency Room group or other 5 physicians that you work with. 6 A. I would suspect there have been. 7 MR. RUF: Continuing objection to 8 that line of questioning. Go ahead. 9 Q. The case you were dropped from 14 years ago, what 10 was that all about? 11 A. A person who I admitted with an cute abdomen who 12 wound up to have a complicated perforated 13 appendix. 14 Q. Was the initial claim that you failed to diagnose 15 the perforated appendix? 16 A. We failed to diagnosis the appendicitis occurred 17 on a previous visit to the emergency department. 18 I was named along with many other hospital staff 19 and physicians in the lawsuit. 20 Q. Do you have any idea roughly how many cases in 21 Cook County are filed each year against your 22 group or members of your group? 23 A. I have no idea. 24 MR. HIRSHMAN: Objection. 25 Q. Do your colleagues ever discuss with you when 38 1 they have been sued? Are you aware of any other 2 lawsuits? 3 A. In general, no. 4 MR. RUF: Objection. 5 Q. You're not aware of any other suits ever filed 6 against anybody else in your group? 7 MR. RUF: Objection. 8 MS. REINKER: Mark, if you want a 9 continuing objection you can have it. 10 MR. RUF: That's fine. 11 Q. Doctor, are you aware of any other lawsuits filed 12 against anybody else in your group? 13 A. I have heard of one or two lawsuits that have 14 arisen in our practice. 15 Q. Now, you are the medical director for the group, 16 correct? 17 A. Yes, I am. 18 Q. Have you ever read any articles or looked up any 19 literature on aortic thoracic dissections? 20 A. I have probably seen a handful of articles over 21 the years in textbooks on aortic dissection. 22 Q. Do you have any knowledge about the percentage of 23 thoracic aortic dissections that are not 24 diagnosed until autopsy? 25 A. I cannot give you a percentage, but it occurs. 39 1 Q. It occurs fairly often, doesn't it? 2 A. It occurs not in a minority of the cases. 3 Q. So that would mean it occurs in the majority of 4 cases. 5 MR. RUF: Objection. 6 Q. Is that correct? 7 A. It occurs in some percentage of cases. It is not 8 the majority in my experience. 9 Q. It is a substantial proportion of the time the 10 diagnosis is not reached until autopsy? 11 MR. RUF: Objection. 12 A. I do not know the percentage. I know it is not 13 minimum, but it is not majority. 14 Q. You would agree that that can be, it can be a 15 very difficult diagnosis to make? 16 A. It can present in a difficult to diagnose 17 fashion. 18 Q. I'm sorry, I didn't hear that whole answer. 19 A. It can be a difficult diagnosis to make. 20 Q. What are the classic symptoms of a thoracic 21 aortic dissection? 22 A. Classic symptoms are chest pain, pressure, 23 discomfort that starts fairly suddenly, tends to 24 move into different areas of the back and chest. 25 Q. And this is usually a crushing, ripping or 40 1 tearing pain, correct? 2 A. In the classic sense it is described as tearing. 3 Q. Are you aware of any lawsuits that have been 4 filed against any of your colleagues for failing 5 to diagnose an aortic dissection? 6 A. I'm not aware of any. 7 Q. Are you aware of any lawsuits filed against any 8 of your colleagues for failing to diagnose a 9 myocardial infarction? 10 A. I'm not actually aware of any. 11 Q. None in your group? 12 A. I'm not aware of any. 13 Q. How many aortic dissections have you diagnosed? 14 A. Somewhere between five and ten. 15 Q. When is the most recent? 16 A. Within the last two years. 17 Q. It can't be anything more specific than within 18 the last two years? 19 A. Roughly a year and a half ago. 20 Q. Do you know what the outcome was in that case? 21 A. Successful aortic surgery. 22 Q. Any of the five or ten that have died? 23 A. To my knowledge, no. 24 Q. Do you know the outcomes of all the five to ten 25 cases? 41 1 A. The majority of them, yes, because they were 2 admitted and treated at the University of 3 Chicago. 4 Q. The one that occurred a year and a half ago, what 5 were that patient's presenting symptoms, do you 6 remember? 7 A. Chest pain and vomiting. 8 Q. Was it the classic sort of chest pain? 9 A. It was not classic, but suggestive. 10 Q. What suggested it? I mean, how was it 11 suggestive? What do you mean by that? 12 A. The clinical scenario involved a patient with 13 hypertension who did not have known coronary 14 disease who presented with restlessness and a 15 chest discomfort that was migratory in her chest. 16 Q. Was it a severe chest pain? 17 A. It was moderately severe. 18 Q. And that patient was admitted to your own, to the 19 University of Chicago? 20 A. That patient presented to the emergency 21 department at University of Chicago. 22 Q. And was admitted to the same institution? 23 A. Exactly. 24 Q. Do you know where in the aorta that dissection 25 occurred? 42 1 A. It was a Type A proximal dissection. 2 Q. The facility in which you work, how many -- 3 physically, are there examining rooms, examining 4 cubicles? 5 A. It's a U-shaped, open, 17 bed emergency 6 department with associated three critical care 7 rooms and an Urgent Care center. 8 Q. Okay. Is there -- you know, in this case that 9 we're involved in, there is something called the 10 CDU. Do you know what that is, a CDU? 11 A. It's a different name for what sounds like a 12 generic observation unit for chest pain patients. 13 Q. If I recall, some of these units started out 14 being called the chest pain unit and they were 15 established to evaluate patients, correct? 16 A. Correct. 17 Q. And do you have such a facility associated with 18 your Emergency Room? 19 A. We do not. 20 Q. So if you feel a patient needs to be observed 21 rather than sent home, what do you do with them? 22 A. We periodically or frequently use our emergency 23 department as a prolonged stay unit. There are 24 -- we have a chest pain center upstairs run by 25 the cardiologist. If they need monitoring for a 43 1 prolonged period of time, if they are likely to 2 go on to need hospital admission, they are 3 admitted to the inpatient hospital, they are 4 likely to go home within a short -- within a 5 reasonable period of time. They are observed in 6 the emergency department. 7 Q. I mean, you don't have any problem with the 8 concept of a CDU, I presume? Of an observation 9 unit? 10 A. Not necessarily. They are functional in many 11 systems. 12 Q. How many physicians are on duty with your group 13 for any -- at any given shift? 14 A. There is either one or two attending physicians, 15 three or four -- three to five residents, and a 16 medical student. 17 Q. In a nonteaching facility, a nonteaching 18 Emergency Room, what is your understanding of 19 appropriate staffing? 20 A. Appropriate staffing is usually one physician per 21 24 hour period round the clock under a volume of 22 24,000. 23 Q. What sort of a recordkeeping system do you have 24 in place? 25 A. We have paper templated charts. 44 1 Q. And what does that mean? 2 A. Physician records and nursing records are 3 handwritten on paper. 4 Q. Okay. So you don't have any kind of a dictation 5 system? 6 A. We do not. 7 Q. So all of your notes would be handwritten? 8 A. They would be, yes. 9 Q. And this is the only facility you have ever 10 worked in, I understand. 11 A. I trained at the University of Illinois, which 12 has several associated hospitals. 13 Q. And did they also have a handwritten chart system 14 or did they have a dictation system? 15 A. The University of Illinois, the inpatient 16 hospital was handwritten. The outpatient side 17 was all telephone dictation. 18 Q. I'm sorry, which side was telephone dictation? 19 A. In-hospital records were paper. Out of hospital 20 records were transcribed via telephone. 21 Q. So how would -- the Emergency Room records, how 22 would they be handled? 23 A. At University of Illinois they were also paper. 24 Q. So you have never worked in an Emergency Room 25 setting where they used a dictation system? 45 1 A. No, I have not, but I am experienced with 2 dictation systems. The fact that I have almost 3 -- I have on several occasions almost 4 incorporated telephone-transcribed dictation into 5 our unit. 6 Q. I'm sorry; I missed that. You have used it in 7 your emergency department? 8 A. With many vendors to pilot and potentially 9 install telephone-transcribed dictation services 10 in our emergency department. 11 Q. But you have not chosen to do that yet? 12 A. We have not. 13 Q. Why not? 14 A. Turn-around time, cost, and complexity of 15 multiple physicians entering on the same patient. 16 Q. You are aware that sometimes those systems can 17 also break down or malfunction? 18 A. I would imagine they do, yes. 19 Q. Now, I would like you to take a look at your two 20 reports in this case. You have reviewed the 21 reports, I presume, recently? 22 A. Yes. 23 Q. And in Cuyahoga County here we have a rule that 24 you need to put into your report any opinions you 25 are going to render or at least the subjects 46 1 about which you are going to render opinions. 2 I gather that these reports do fairly 3 summarize the opinions you hold in this case? 4 A. They do. 5 Q. Are there any opinions you are going to be 6 rendering at trial that are not stated in these 7 reports, and I don't mean -- I know you are going 8 to have facts and things that you will use to 9 support your testimony, but in general, do those 10 reports contain the opinions you are going to 11 render? 12 A. The basic opinions are still the same. 13 Q. Okay. I gather that you will not be rendering 14 any opinions in this case concerning Mrs. 15 Broncaccio's care and treatment prior to the 16 Emergency Room visit on December 7 of 1997. 17 A. I doubt so, yes. 18 Q. So the answer then is no, you will not be 19 rendering opinions about the care before 20 December 7 of '97? 21 A. I did not plan to. 22 Q. And I gather you will also not be rendering any 23 opinions about the type of treatment that Mrs. 24 Broncaccio would have had or the outcome after -- 25 if the diagnosis had been made on December 7 47 1 or 8, 1997. 2 A. I will not be, no. 3 Q. Now, I would like you to look at what we have 4 marked as Exhibit B, and that's the letter to 5 Mr. Hirshman, the first letter. 6 A. Okay. 7 Q. Now, in that report, you make the statement that, 8 in the beginning of your second paragraph, you 9 list Mrs. Broncaccio's presenting symptoms. 10 Do you see that sentence? 11 A. I do. 12 Q. The first presenting symptom you mention is chest 13 pressure. 14 A. Yes. 15 Q. You have reviewed the records. I gather you 16 would agree that the patient, that Mrs. 17 Broncaccio never complained of crushing, ripping 18 or tearing pain. 19 A. She did not. 20 Q. In fact, I think the worst type of pain she 21 reported to anybody -- well, frankly, she didn't 22 use the word pain, she called it pressure, didn't 23 she? 24 A. I think the majority of the words were pressure. 25 Q. And I think the highest degree or the highest 48 1 measurement she ever gave it was 4 out of 10 and 2 it was usually 2 out of 10. Do you recall that? 3 A. That seems consistent. 4 Q. Would it be fair to call that or characterize 5 that as low grade chest pain? 6 A. Low to moderate. 7 Q. Now, I gather you have seen patients come into 8 the Emergency Room with low to moderate pain, 9 chest pain? 10 A. I have. 11 Q. That could be caused by any number of things, 12 correct? 13 A. Correct. 14 Q. In general, looking at that complaint only, what 15 is the first thing on your list as a possible -- 16 strike that. 17 Would you agree that the most likely cause of 18 low to moderate chest pain described as this 19 patient described it would be something in the GI 20 tract? 21 A. I think the most common pain, pressure symptom in 22 that grade would probably never be clearly 23 diagnosed but would include several organs, 24 including the GI tract. 25 Q. What do you mean, the most commonly, it would 49 1 never be diagnosed. What do you mean by that? 2 A. It's difficult to prove that low grade 3 indigestion, a little bit of acid reflux and 4 pressure sensations in an emergency department 5 are clearly related, but when looked at, 6 nondescript chest pain that doesn't turn out to 7 be a significant illness, gastrointestinal is one 8 of the frequently ascribed diagnoses. 9 Q. Can you give any percentage to that, what 10 percentage of these patients coming in with low 11 grade chest pain would turn out to have a GI 12 problem? 13 A. I don't think I could give you an accurate 14 percentage, but it is maybe a third. 15 Q. You said -- let's say roughly 33 percent turn 16 out, would turn out to have a GI problem. What 17 percent would never be diagnosed? 18 A. Potentially another 30 percent. 19 Q. Okay. Going down the list of other possible 20 causes of this symptom, what would come next in 21 frequency? 22 A. After gastrointestinal, it really does depend on 23 a number of things. Age group, risk factors, and 24 the history around the chest pressure. 25 Q. What are some other possible causes of this 50 1 complaint? 2 A. Low pain, coronary ischemia, pulmonary embolism, 3 aortic dissection, pneumonia, pneumothorax. 4 Q. Would pulmonary-related problems be something a 5 substantial percentage of the time? 6 A. It would be in some. 7 Q. Okay. Well, I'm just trying to get -- in this 8 group of a hundred people who come in with low 9 grade chest pain, 33 percent are not diagnosed, 10 33 percent turn out to be GI; what percent 11 roughly would have some pulmonary-type problem? 12 A. I'm going to have to say that is going to be very 13 difficult to give you absolute percentages 14 because if you give me chest pain in all comers, 15 I have to have certain parameters, like age 16 group, duration, et cetera. 17 Q. Well, let's talk about people in their, the 18 elderly patient. 19 A. Say a 67 year old lady with chest pressure. 20 Q. Okay. 21 MR. HIRSHMAN: The only thing 22 we're talking about still, Susan, right, is 23 just chest pressure? 24 MS. REINKER: Just the one 25 symptom. 51 1 MR. HIRSHMAN: All right. 2 A. So I would say a half or so would probably never 3 be diagnosed or presumed to be gastrointestinal. 4 Some portion in the double digits would 5 probably be -- tennish percent would be 6 pulmonary, and probably the rest would be 7 cardiovascular. 8 Q. Aortic thoracic dissection is a fairly uncommon 9 condition, isn't it? 10 A. It is. 11 Q. So out of these hundred patients who come in with 12 this symptom of low grade chest pain, how many of 13 them would turn out to have an aortic thoracic 14 dissection? 15 A. Probably only a couple. 16 Q. You think it's as much as two percent? 17 A. Maybe around that number. 18 Q. Anxiety could be another cause? 19 A. Low on my list. 20 Q. But that's another potential cause of this 21 particular symptom? Was that a yes? We didn't 22 get an answer to that. 23 A. I would have a hard time ascribing chest pressure 24 related to anxiety. 25 Q. Now, on your list of symptoms here, the second 52 1 symptom you list that Mrs. Broncaccio presented 2 was near syncope? 3 A. Yes. 4 Q. And by that I presume you are referring to the 5 episode described on the EMS record of five 6 minutes, I think it says, of staring into space? 7 A. Correct. 8 Q. Now, that was a one-time event, correct? 9 A. Correct. 10 Q. What sorts of things could make a patient do 11 that? 12 A. A low cardiac flow state. 13 Q. Anything else? 14 A. A seizure. 15 Q. TIA? 16 A. Potentially, yes. 17 Q. What do you mean by a low cardiac flow state? 18 A. Something that doesn't allow adequate supply of 19 blood to the brain. 20 Q. Now, there is some mention in the record of a 21 vagal episode, I think that -- did I use that 22 correctly? 23 A. There is -- 24 Q. A vasovagal episode? 25 A. Yes. 53 1 Q. Is that something you are familiar with? 2 A. Yes. 3 Q. What does that mean? 4 A. That's an exaggerated reflex where the blood 5 pressure and pulse rate drop, associated with a 6 lower cardiac output and inadequate perfusion to 7 the brain before that. 8 Q. So a vasovagal episode could cause this near 9 syncopal episode too? 10 A. Yes. 11 Q. What causes a vasovagal -- am I saying that 12 correct, doctor, or is it a vagal episode? 13 MR. HIRSHMAN: When you say "this 14 episode," you're not talking about this 15 patient's episode, you're talking 16 generically about near syncopal events, 17 correct? 18 MS. REINKER: Correct. 19 MR. RUF: You're talking about 20 syncope in isolation as well, right? 21 MS. REINKER: I would like to know 22 which one of you is handling this 23 deposition. 24 MR. RUF: We are both counsel of 25 record and both entitled to state our 54 1 objections on the record. 2 MS. REINKER: I'm not familiar 3 with the situation where two people object 4 simultaneously. Courts don't usually 5 permit that. 6 MR. HIRSHMAN: I'm not objecting. 7 I just wanted a clarification. It's not an 8 objection. 9 MS. REINKER: Okay. 10 Q. Now, what kinds of -- I think, doctor, I was 11 asking you is it a vasovagal episode or just a 12 vagal episode? 13 A. It goes by many terms. Vagal is a generic term. 14 Q. Is that the vagus nerve, the same nerve that can 15 make people have hiccups? 16 A. That's the phrenic. 17 Q. The phrenic nerve, I'm sorry. What can cause a 18 patient to have a vagal episode? 19 A. A host of things. Most commonly, pain. 20 Q. Anything else? What else is in the host? 21 A. Pain, anxiety, fear, drugs, abnormal innervation, 22 heightened innervation to the heart. Blood 23 pressure medications. 24 Q. Okay. So you mentioned the next presenting 25 symptom that Mrs. Broncaccio had was hypotension. 55 1 A. Correct. 2 Q. How do you define hypotension? 3 A. It's relative to your age. The normal adult has, 4 a blood pressure of 120 over 80 is considered 5 normal. 6 Q. So you think anything below 120 over 80 is 7 hypotension? 8 A. I would say in a healthy adult without another 9 reason, a drop in systolic pressure between 10 10 and 20 points would be hypotension. 11 Q. I'm sorry. Repeat that if you would. 12 A. In blood pressure, the larger number, a systolic 13 number of more than 10 to 20 points below, let's 14 say 120, or below their baseline. 15 Q. Did you have any impression of -- I mean, how did 16 you understand Mrs. Broncaccio to demonstrate 17 hypotension? 18 A. It was the EMS run sheet with the low blood 19 pressure. 20 Q. So you're talking about the symptoms that were 21 reported on the EMS run sheet prior to her 22 arrival in the Emergency Room? 23 A. Yes. 24 Q. Okay. Now, certainly a patient who has 25 hypotension does not need to receive medication 56 1 to reduce their blood pressure. 2 A. Not at that moment, no. 3 Q. Hypotension is not known to be an associated 4 symptom of aortic dissection, is it? 5 A. It actually can be, yes. 6 Q. Can you show me or tell me anywhere -- well, 7 strike that. 8 Is it your testimony that hypotension is a 9 known symptom of an aortic dissection? 10 A. It's a possible symptom of an aortic dissection. 11 Q. It's not usually listed as one of the classic 12 symptoms, is it? 13 A. Not of a dissection without rupture. 14 Q. So hypotension occurs when the dissection causes 15 the aorta to rupture and the patient starts 16 bleeding out, right? 17 A. It can also occur when there is a significant 18 false lumen created and blood is diverted into 19 that. 20 Q. Now, bradycardia, how do you define bradycardia? 21 A. Below 60 beats per minute. 22 Q. Now, it's my understanding that bradycardia is 23 not, is also not known to be a symptom of an 24 aortic dissection, is that correct? 25 A. That would be correct. 57 1 Q. I gather you would agree that at the time Mrs. 2 Broncaccio arrived in the Emergency Room it was 3 appropriate to consider a myocardial infarction 4 or some other cardiac event as being the possible 5 cause of her problem? 6 A. It would be. 7 Q. Would that be the first thing you would have 8 investigated if you were seeing this patient? 9 A. It would have been. 10 Q. Now, you have reviewed her EKGs while she was -- 11 I think there were several of them that were done 12 while she was in the Emergency Room and then 13 later in the CDU? 14 A. There were two or three electrocardiograms. 15 Q. And in your opinion they were all normal? 16 A. Very. 17 Q. I'm sorry? 18 A. Very normal. 19 Q. Now, a patient can have a normal EKG even in the 20 face of an MI, can't they? 21 A. Less than five percent. 22 Q. But five percent will have a normal EKG even if 23 they are having an MI. 24 A. Yes. 25 Q. I'm sorry, did you say something? 58 1 A. Presentation to the emergency department, five 2 percent of people having a myocardial infarction 3 can have what is termed a normal 4 electrocardiogram. 5 Q. If a patient -- what makes an EKG become 6 abnormal? Is it actual heart damage? 7 A. In general it's ischemia, which is reversible 8 damage, or infarction, which is irreversible 9 damage. 10 Q. What percent of patients who are not having an MI 11 but have angina will have a normal EKG? 12 A. If pain is ongoing, the likelihood is that the 13 electrocardiogram will show abnormality. 14 Q. Well, you said that five percent of the time a 15 patient can be actually having an MI and still 16 have a normal EKG. 17 A. Yes. 18 Q. What percent of the time can they be having 19 angina and still have a normal EKG? 20 A. If they are not having pain it is perfectly -- it 21 is not uncommon for them to have a normal 22 electrocardiogram. The episodes of pain usually 23 precipitate the abnormalities in the 24 electrocardiogram that may last 20 minutes or so. 25 Q. What if they are having low grade pain? 59 1 A. Usually an abnormality in the electrocardiogram. 2 It is either apparent initially or develops over 3 time. 4 Q. What percent of the time, though, I presume it is 5 something more than five percent, a patient can 6 be having low grade pain and still have a normal 7 EKG in the face of angina? 8 A. I don't think I can put a percentage on that, but 9 it's somewhat more than five percent, I would 10 say. 11 Q. So then I gather you would agree that a normal 12 EKG does not in and of itself rule out angina or 13 rule out an MI? 14 A. It puts it lower on the list. 15 Q. Now, what makes cardiac enzymes abnormal? 16 A. Irreversible damage to the heart. 17 Q. And how long does it take for the enzymes to 18 become abnormal after the heart damage has 19 occurred? 20 A. Typically, an hour or two. It may take longer. 21 Q. Why is it that physicians recommend a series of 22 three sets of cardiac enzymes? 23 A. It's because if the occlusion of the artery is 24 not complete or they present very early, it may 25 take several hours to manifest enzyme links 60 1 documenting an infarction. 2 Q. So again you would not rely on one set of enzymes 3 to rule out an MI? 4 A. Depending on the timeframe, usually not. 5 Q. If a patient is having anginal pain, their 6 enzymes will still be normal, won't they? 7 A. Typical angina is described as pain that lasts 8 less than 20 minutes. Greater than 20 minutes is 9 most likely a myocardial infarction. 10 Q. But if a patient is having anginal pain, their 11 enzymes will not change, will they? 12 A. If they have angina of brief and reversible 13 ischemic injury to the heart but not true 14 infarction, their enzymes are likely to remain 15 normal. 16 Q. So then again the answer to my question is yes, a 17 patient can have anginal pain with their enzymes 18 still remaining normal? 19 A. With qualifications, yes. 20 Q. The reason that a series of three sets of enzymes 21 is recommended is because you really cannot rule 22 out an MI until all three sets of enzymes have 23 been completed, correct? 24 A. It's a constellation of the history, the changes 25 in electrocardiography, and most importantly, the 61 1 presence or absence of abnormal cardiac markers 2 in the enzyme acids. 3 Q. Well, doctor, do you in your own practice rule 4 out an MI before the three sets of enzymes have 5 been completed? 6 A. Only if the pain has been of prolonged duration 7 prior to presentation. 8 Q. And what do you consider prolonged duration? 9 A. Several hours. 10 Q. So if the pain began immediately before 11 presentation, you would not rule out an MI until 12 all three sets of enzymes have been completed? 13 A. No. 14 Q. Would you agree that the quality and the type of 15 chest pain Mrs. Broncaccio complained about or 16 chest pressure she complained about did not 17 change while she was in the Emergency Room? 18 A. It did not. 19 Q. I gather you would agree there was no complaint 20 of back pain while she was in the Emergency Room? 21 A. Per the medical record, it was not during the 22 emergency department stay. 23 Q. Do you know of any evidence of back pain while 24 the patient was in the Emergency Room? 25 A. There is a deposition by one of the daughters 62 1 that states she had pain in her back while she 2 was in there. 3 Q. Did you read the depositions of both of the 4 daughters? 5 A. I did. 6 Q. And what did the other daughter say about that? 7 A. I don't recall her mentioning -- actually, I 8 don't recall what she mentioned about it. 9 Q. If we assume for the moment that there was no 10 complaint of back pain while the patient was in 11 the Emergency Room, okay, would you agree that 12 the care she received up until 2:15 or 2:20 when 13 she left the Emergency Room was appropriate? 14 A. I would. 15 Q. Now, how many times did you see a complaint of 16 back pain recorded in the records? 17 A. I actually think it was several times. Probably 18 two or three. 19 Q. Well -- 20 A. If you want, I will look in the nursing notes. 21 Most of this was recorded in the nursing notes. 22 Q. In the CDU nursing notes, correct? Or I'm sorry. 23 A. First complaint of back pain I noticed is 3:00, 24 and at 3:30 requesting a heating pad at the 25 nurses' station and the doctor is informed and 63 1 they all sort of run together. 2 Q. So roughly between 3:00, 3:30, around that time, 3 point in time, is the first complaint you see 4 noted of back pain? 5 A. In the medical record, yes. 6 Q. Are there any other complaints of back pain until 7 12:00 noon the next day? 8 A. At noon the next day is chest and back pain. Or 9 pressure. 10 Q. Actually, she calls it pressure again, doesn't 11 she? 12 A. Yes. 13 Q. Have you ever had a patient who has been lying on 14 an ER cart complaining that their back hurt or 15 their back was bothering them? 16 A. Not without pre-existing back disease or on a 17 spine board. 18 Q. You have never had anybody, an older patient in 19 the Emergency Room say their back was bothering 20 them from lying on the cart? 21 A. I think it is very rare. 22 Q. But that could happen, couldn't it? 23 A. If you had pre-existing back conditions, 24 especially. 25 Q. Doctor, did you ever happen to be a patient in an 64 1 Emergency Room, you yourself? 2 A. Not in many, many years. 3 Q. So you have never as an adult had occasion to lie 4 on one of those carts for three hours? 5 A. No. 6 Q. Now, in your report, and again I'm looking at 7 Exhibit B, the letter to Mr. Hirshman, you make 8 -- about midway through the second paragraph you 9 make the statement "this constellation of 10 complaints" okay, and then you go on to talk 11 about some other things, but when you refer to 12 "this constellation of complaints," what were you 13 specifically referring to? 14 A. Chest pain. Chest discomfort, back pain, 15 abdominal pain, refractory nausea and vomiting. 16 Hypotension, described as restlessness. 17 Q. So it was because of that whole picture that you 18 put together that you felt other things should 19 have been done, correct? 20 A. Correct. 21 Q. Now, I don't know, where did you get the 22 complaint of abdominal pain? 23 A. Either in the medical records or one of the 24 depositions by the daughter, but I have a feeling 25 it's the CDU nursing notes. 65 1 Q. Would you find that for me if you can, because I 2 didn't see abdominal pain anywhere. 3 A. Nausea, vomiting, can't sleep. I don't find it. 4 It may have been in one of the depositions. 5 Q. Now, the patient also developed diarrhea, didn't 6 she, towards morning? 7 A. She did. 8 Q. Now, diarrhea is not a symptom of an articular 9 dissection, is it? 10 A. If it involves the gastrointestinal tract. 11 Q. If I look at a list of the symptoms of an aortic 12 dissection, will I see diarrhea listed? 13 A. It is a possible one, but may not be listed in 14 the most common presenting. 15 Q. I mean, diarrhea is certainly not a symptom that 16 a patient would complain about and a doctor would 17 immediately think they had an aortic dissection, 18 would they? 19 A. You're correct. 20 Q. Same thing with nausea and vomiting, they are not 21 the first -- they are not physical problems that 22 point to a diagnosis of aortic dissection? 23 A. Certainly not by themselves. 24 Q. I gather that you felt consideration of doing a 25 CT scan was not indicated until the complaint of 66 1 back pain was mentioned. 2 A. That would have been the latest that a 3 consideration a CT scan should have been highly 4 undertaken. 5 Q. Because I got the impression that it was this 6 constellation of symptoms you were talking about 7 that you felt should have prompted doing a CT 8 scan. 9 A. I believe that the consideration for aortic 10 dissection should have remained in the minds of 11 the physician and nursing staff or most of the 12 physicians taking care of the patient because of 13 the pre-existing history, and that once 14 myocardial ischemia had really reliably been 15 excluded, and especially with the addition of 16 back pain, that in that timeframe a CAT scan 17 should have been ordered, around 3:00, 3:15. 18 Q. You think around 3:00 in the morning is when the 19 CAT scan should have been considered? 20 A. It should have been considered with a normal 21 electrocardiogram, ongoing pain, a second normal 22 electrocardiogram. The series of normal 23 electrocardiograms in the presence of ongoing 24 pain, the development of back pain, restlessness, 25 and the two risk factors, hypertension and aortic 67 1 insufficiency should have prompted the decision 2 to obtain a CAT scan. 3 Q. But it's basically when all these ongoing 4 symptoms are put together along with other things 5 that you consider important you think the 6 consideration should have been done for a CT 7 scan? 8 MR. HIRSHMAN: He didn't say 9 consideration. He said it should have 10 prompted a CT scan. 11 A. They should have considered a CT scan on 12 presentation with normal electrocardiogram and 13 the presence of aortic insufficiency. 14 Q. Now, you have mentioned that a couple of times. 15 What does aortic insufficiency have to do with 16 all this? 17 A. When the aortic valve is incompetent, it dilates 18 and allows blood to rush backwards into the 19 heart. It's a significant predisposition to a 20 tear at the ring of the aortic valve. 21 Q. Is aortic insufficiency a risk factor for 22 developing aortic dissection? 23 A. Yes. 24 Q. Can you name any literature that agrees with 25 that? 68 1 A. I cannot name any literature, but it is a risk 2 factor. 3 Q. And how do you know that? 4 A. Training, articles, textbooks. I cannot quote 5 them specifically. 6 Q. What percentage of patients that have aortic 7 insufficiency go on to develop an aortic 8 dissection? 9 A. I don't think I could speculate on a percentage. 10 Q. But you believe it's a risk factor? 11 A. I believe it is a risk factor. 12 Q. Any other risk factors that this lady had for 13 aortic dissection? 14 A. Hypertension, which is the number one risk factor 15 for aortic dissection. 16 Q. And can you tell what percent of patients who 17 have hypertension develop aortic dissection? 18 A. I do not know that percent. Hypertension is a 19 very common, also the most common risk factor for 20 aortic dissection. 21 Q. Hypertension? 22 A. Yes. 23 Q. Certainly there are lots of people in this 24 country that have high blood pressure that don't 25 develop aortic dissections? 69 1 A. Yes. 2 Q. In fact, it would probably be a small minority of 3 people that have hypertension that develop aortic 4 dissection, correct? 5 A. Correct. 6 Q. And again, I think you said it was roughly in the 7 3:15 to 3:30 range that a CT scan should have 8 been ordered? 9 MR. RUF: Objection, he said 10 several times it should have been 11 considered before, even on presentation. 12 MR. HIRSHMAN: Come on, Susan. He 13 said 3:00. 14 MS. REINKER: Okay. 15 Q. So then I guess Mr. Hirshman says at 3:00 Dr. 16 Haluska should have requested a CT scan, correct? 17 Is that your opinion, doctor? 18 A. The scan should have been considered during the 19 entire course and definitely should have been 20 ordered upon the other symptoms I had discussed. 21 Q. Of the 100 or so patients who are admitted to 22 your Emergency Room, this group you're talking 23 about before who have low grade chest pain, what 24 percent of them get CT scans? 25 A. A couple percent. 70 1 Q. Two percent, is that? 2 A. Maybe. It's hard to speculate on the percentage, 3 but it would be a couple. 4 Q. Now, in your report you make the statement or you 5 come to the conclusion that Dr. Haluska -- I 6 don't know that you use these words but that he 7 fell below the standard of care for not ordering 8 a CT scan. Is that your opinion? 9 A. That's my opinion. 10 Q. Is there any other way that you feel Dr. 11 Haluska's care fell below recognized standards? 12 A. No. 13 Q. I'm sorry? There is a noise; we didn't hear the 14 answer. 15 A. No. 16 Q. Is there any way that you feel the care of anyone 17 else who saw Mrs. Broncaccio on December 7 or 18 December 8 fell below recognized standards? 19 A. I know that at 3:00 he was notified of the back 20 pain and the need or the desire for a heating 21 pad. I think her condition changed throughout 22 her CDU course, including the development of back 23 and chest pain together, some gastrointestinal 24 discomfort, and it does not appear that the 25 physician was notified of these further changes 71 1 in her clinical condition. 2 Q. Now, would you take a look at those CDU records, 3 please? 4 A. Yes. 5 Q. And isn't it a fact that there is no complaint of 6 chest pain or chest pressure from roughly, I 7 think 3:00 in the morning on? 8 A. Noon the next day. 9 Q. So between, I think it was 2:25 or 2:30 in the 10 morning and noon, there was no recorded complaint 11 of chest pressure, correct? Or any chest 12 complaints. 13 A. Not until noon, correct. 14 Q. And there is only one complaint of back pain and 15 that's the one around 3:00 in the morning? 16 A. There is a chest heaviness at 2:25, 4 on a scale 17 of 10. 18 Q. Correct. 19 A. Then there is the back pain at 3:00, the doctor 20 notified. Then the gastrointestinal complaints 21 that go on through the early morning. 22 Q. The gastro -- now, the diarrhea, nausea and 23 vomiting begin at roughly 5:00 in the morning, 24 correct? 25 A. Correct. 72 1 Q. Okay. But from the records it would appear that 2 there were no continuing complaints of chest pain 3 or back pain from 3:30 on. 4 A. The medical records do not state that, no. 5 Q. Now, again, assuming that to be correct, the 6 records to be correct for the moment, my question 7 to you was are you critical of anyone else's care 8 other than Dr. Haluska? 9 A. Assuming that the nurses are not aware of other 10 chest complaints that may or may not have been 11 brought out in depositions, I do not have other 12 complaints about the caregiver. 13 Q. Now, you have looked at the autopsy, correct? 14 A. Yes. 15 Q. And I believe the autopsy describes a tear in the 16 intimal wall of the aorta, beginning at the 17 aortic root. 18 A. It did. 19 Q. Is it your -- and you would agree, I gather, that 20 apparently the tear began close to the heart and 21 then moved distally. 22 A. Yes. 23 Q. That's the dissection, when it moved distally. 24 Correct? 25 A. Correct. 73 1 Q. Now, that is not what caused Mrs. Broncaccio's 2 death. 3 A. It did not. 4 Q. Do you have any opinion as to what stage this 5 dissection was at at 11:30 at night or if it had 6 even begun at 11:30 at night when she was 7 admitted to the Emergency Room? 8 A. Her sudden chest complaint and the cardiovascular 9 response she had to the pain would suggest that 10 the diagnosis -- the dissection initiated around 11 the time of her event at home that prompted the 12 paramedics. 13 Q. Are you aware, I think both of her daughters 14 testified that she did not complain of pain at 15 home? 16 A. Pressure. 17 Q. Correct. So she never complained of this sudden 18 ripping, tearing chest pain. Correct? 19 A. She had chest discomfort and a fainting, near 20 syncopal episode. 21 Q. Correct, but there was no complaint at the time 22 of the event of severe ripping, tearing chest 23 pain. 24 A. It was established that the complaint has been 25 pressure. 74 1 Q. Okay. And I'm going back. Even at home when the 2 event happened, it was the same type of low grade 3 chest pain? 4 A. That's my recollection. 5 Q. But you believe the dissection began at the time 6 of that event at her home? 7 A. I do. 8 Q. Do you believe it progressed over the next hours 9 or did it, you know, reach its full maturity and 10 then just stop? 11 A. I believe it progressed down her aorta until 12 about 3:00 in the morning. 13 Q. Do you have any opinion what level the dissection 14 had reached, say at 11:30 p.m. when she was 15 admitted? 16 A. It had probably not gotten -- not gone into the 17 lower chest because of the lack of back pain. 18 Q. You think it had gone around the arch? 19 A. It probably had. 20 Q. Okay. 21 A. Probably confined to somewhere in the arch when 22 she presented. 23 Q. And then when do you believe that it went into 24 the lower chest? 25 A. Somewhere between 11:00 and 3:00. 75 1 Q. Okay. Low grade chest pain is an unusual 2 presentation for a thoracic aortic dissection, 3 isn't it? 4 A. There are typical and atypical presentations. 5 Unfortunately, the aortic and thoracic dissection 6 has many atypical presentations. 7 Q. And Mrs. Broncaccio's case would certainly fall 8 into the atypical presentation category. 9 A. It was not classic, although it had some 10 significant typical features. 11 Q. What was typical? 12 A. Chest, back pain, and two risk factors. 13 Q. What was atypical? 14 A. Not sudden, severe tearing. 15 Q. Anything else atypical about it? 16 A. Not necessarily. 17 Q. Well, the diarrhea would be atypical. 18 A. If you have ischemia, you frequently have 19 abdominal complaints and/or diarrhea. 20 Q. Is it your belief that by 5:00 in the morning 21 Mrs. Broncaccio already had ischemic bowel? 22 A. I believe that that's a possibility. 23 MR. HIRSHMAN: At what time? 24 5:30, did you say? 25 MS. REINKER: I think she 76 1 developed the diarrhea around 5:00 in the 2 morning. 3 Q. Correct me if I'm wrong, doctor. 4 A. That sounds right. 5 MS. REINKER: And if he is 6 attributing that to ischemic bowel I asked 7 whether she already had ischemic bowel at 8 5:00 in the morning. 9 MR. HIRSHMAN: Gotcha. 10 A. It is actually 6:00 a.m. 11 Q. And you think by then she had enough impairment 12 of the vascular supply to her bowel to cause 13 diarrhea? 14 A. It's certainly possible. It's not clear to me 15 from the autopsy how much bowel involvement she 16 had, and what stage or degree of bowel ischemia 17 that was present. 18 Q. Is it possible that she had a case of the flu at 19 the same time all this was going on? 20 A. Interesting coincidence, but certainly possible. 21 Q. Now, how did your second report come about, if we 22 can look at that. 23 By the way, before I finish with Exhibit B I 24 just want to make sure we have covered everything 25 that you are going to be testifying about with 77 1 regard to the discussion of Exhibit B, in Exhibit 2 B, in your first report. 3 A. I think we've covered the entire. 4 Q. Okay. Now, how did Exhibit C come about, Report 5 Number 2? 6 A. I think, if I remember, I was asked to take a 7 look at the medical records, hand transcribed 8 physical examination. I also believe depositions 9 of Dr. Haluska and the electronic encounter 10 system for Kaiser. 11 Q. Now, point number one that you make in this 12 report, you talk about the dictated medical 13 records missing a section. 14 A. Correct. 15 Q. Now, you say in your experience it would be 16 unusual for an entire section of a medical record 17 to be missing from a dictation. 18 A. That would be correct. 19 Q. Now, you don't have any experience with dictated 20 records, though, do you? 21 A. I have anecdotal experience with many dictation 22 companies and many hospitals that use dictated 23 medical records. 24 Q. Anecdotal means stories they have told you about? 25 A. No, it's personal investigation into the 78 1 operations, quality, performance, turnaround 2 times, et cetera, various systems used in 3 Chicagoland emergency rooms and promoted or used 4 by physicians who are interested in electronic 5 medical records to survey whether they were 6 accurate, timely and appropriate for inclusion in 7 our emergency department. 8 Q. But you have never used a dictation system on a 9 day-to-day basis year after year? 10 A. Only in my outpatient clinic. 11 Q. There were actually a number of sections of this 12 ER record that were not, that did not come 13 through on the dictation, weren't there? 14 A. Actually, I need to also -- we used electronic 15 dictation, transcribed dictation for many other 16 areas of the hospital and I frequently use 17 records on our electronic medical records system 18 that have been transcribed by many different 19 transcription services to reflect encounters 20 throughout our institution. 21 Q. Have you ever seen any of them where part of the 22 dictation did not get transcribed and not come 23 through? 24 A. I actually have not seen just this section 25 omitted before. 79 1 Q. Now, in this particular case, there were a number 2 of sections that did not come through on the 3 dictation, weren't there? 4 A. It was my recollection given the records that 5 only the physical examination was deleted from 6 the electronic -- the electronic medical record 7 that was transcribed during that emergency 8 department visit. 9 Q. Would you take a look at that, at the dictation? 10 A. Okay. I have it in front of me. 11 Q. Okay. Now, if you look, if you take a look at 12 that there are actually a number of sections that 13 did not get transcribed. 14 A. I think you're probably referring to plan, 15 condition, out and acuity level. 16 Q. That's on that page. And on the previous page I 17 think there are a couple sections as well. 18 A. Family history. 19 Q. Right. What do you think caused this to happen? 20 What do you think happened here? 21 A. There is a template which most of these are 22 driven by, the physical examination is almost 23 never neglected in a transcription, whereas 24 social and family history may not be relevant and 25 may not be dictated, so that deletion is not 80 1 something I would find unusual. Plan, condition, 2 and out is actually included in the ED course as 3 a narrative. 4 Q. Do you have any explanation or any opinion as to 5 what happened to cause parts of this dictation to 6 not be here? 7 A. I actually think that given the records that the 8 dictation is complete except for the physical 9 examination, and I believe the physical 10 examination was probably, based on experience, 11 not dictated. 12 Q. Why do you think he didn't dictate it? 13 A. It may have been an oversight. It may not have 14 been performed. 15 Q. Well, you're not disputing the fact that Dr. 16 Haluska examined this patient, are you? 17 A. I think the physician, he probably did a physical 18 examination. 19 Q. Number 2, point two that you make, you talk about 20 the handwritten physical exam. 21 A. I do. 22 Q. You instruct residents, don't you? You teach and 23 supervise residents? 24 A. I do. 25 Q. And if you had an occasion to look at a chart 81 1 that came through for any reason for you to 2 review as medical director of your department and 3 you found something to be omitted, what would you 4 do about it? 5 A. The charts are via administrative routes sent 6 back to the responsible physician, and they are 7 notified that there is an absence of a required 8 part of the record. 9 Q. So you would ask the physician to complete the 10 record? 11 A. Correct. 12 Q. Okay. And I gather you don't have any problem 13 with Dr. Kaforey asking Dr. Haluska to complete 14 the record when he realized there was an 15 omission? 16 A. That would be standard practice. 17 Q. Now, I'm not quite sure what you mean with regard 18 to your comment two here. 19 A. My comment two was based on is the -- is the 20 language and/or findings in the physical 21 examination that was handwritten at a later date 22 consistent with the thought process and the 23 narrative of the dictation that was done real 24 time from the emergency department at her 25 presentation. 82 1 Q. Okay. And I guess I don't understand what your 2 point is here when you, in your second sentence. 3 A. The point, my point is that the physical 4 examination is heavily weighted towards the 5 absence of physical findings that would suggest 6 an impending aortic dissection, where none of the 7 other medical records would suggest that that 8 diagnosis was ever considered or entertained 9 during her course. 10 Q. Well, the only thing you talk about in point two 11 is the presence or absence of jugular venous 12 distention, JVD. Right? 13 A. Yes. 14 Q. Now, have you ever had the experience of a 15 patient that you have seen in the Emergency Room 16 later coming back or later hearing that they had 17 a problem that you did not suspect? 18 A. It has happened. 19 Q. Maybe a patient who -- have you ever had an 20 occasion where a patient that you have examined 21 came back later and died, or died as an 22 outpatient and you later heard that they died? 23 A. Yes. 24 Q. Okay. Now, when that kind of thing happens, it 25 sort of freezes events in your mind, doesn't it? 83 1 A. I'm not sure what you mean. 2 Q. Well, wouldn't that make you think over your 3 examination of that patient carefully? 4 A. It would make me think over the entire treatment 5 plan and evaluation that I delivered to the 6 patient. 7 Q. Okay. And you might be surprised, for example, 8 to learn that the patient had a heart attack and 9 you might say well, goodness, they didn't have 10 any sign of that when I saw them. That might 11 occur to you or you might say something like 12 that, mightn't you? 13 A. Yes. 14 Q. Now, the absence of jugular venous distention, 15 what is the significance of that that particular 16 finding in this case? 17 A. The jugular veins are the return system to the 18 heart that show whether the heart is actually 19 filling correctly or if there is impedence to 20 filling the heart. It is seen in processes such 21 as heart failure, severe lung disease, and 22 pericardial fluid. It is checked not terribly 23 commonly. Or very commonly. 24 Q. Now, you would not expect there to be jugular 25 venous distention in this, in Mrs. Broncaccio 84 1 while she was in the Emergency Room or the CDU, 2 would you? You would not expect that to be 3 present, would you? 4 A. Not until she ruptured into her pericardial sac. 5 Q. The terminal event, which occurred at the time of 6 her death on the afternoon of the 8th. 7 A. Correct. 8 Q. So the fact that Dr. Haluska commented that there 9 was no JVD, you agree that there probably was no 10 JVD? 11 A. I don't dispute that there was not likely to be 12 JVD. 13 Q. Okay. Your third point, you comment on Dr. 14 Ryder's post-resuscitation note. 15 A. Yes. 16 Q. What was the significance of that comment? 17 A. There is discrepancy in the physician-transcribed 18 notes and her post arrest charting as to whether 19 and from what source she had back pain, upper, 20 lower, mid, and there is a section where upper 21 back pain is crossed out. Lower back pain is 22 then written, and some commentary or what the 23 presumed or presumptive causes of death are. 24 Q. And what -- what did you find interesting enough 25 about all that to put in this report? 85 1 A. His comment that there was a lot of discussion 2 about the location of the back pain, and what it 3 potentially signalled as the terminal event. 4 Q. Does that make any difference to you where the 5 back pain was, what level it was at? 6 A. Not necessarily, except that in cases of aortic 7 disruption, it may indicate different levels of 8 disruption. 9 Q. Where would you have expected the back pain to 10 have been in this case? 11 A. In her upper to mid. 12 Q. By the way, you saw Dr. Gajdowski's dictated 13 note, too, didn't you? 14 A. Yes. 15 Q. And did you find anything Dr. Gajdowski had to 16 say interesting? 17 A. I don't believe there was anything that came to 18 my attention out of the ordinary. 19 Q. Well, Dr. Gajdowski felt strongly that this was 20 not an aortic dissection but that the death was a 21 cardiac death. Do you remember that? 22 A. Yes, I do. 23 Q. And would you agree that at that point in time, 24 that was still a fair consideration, that what 25 Mrs. Broncaccio had been suffering from all along 86 1 was a cardiac event? 2 A. I think that diagnosis had been ruled out almost 3 completely. 4 Q. By what? 5 A. Normal electrocardiograms and normal enzymes over 6 a prolonged period. 7 Q. So you're saying by the third serial enzyme, at 8 that point in time you felt that the diagnosis of 9 any cardiac problem was ruled out? 10 A. I think that to do three sets of enzymes over 24 11 hours has been outdated for many years and that 12 most exclude myocardial infarction protocols go 13 for between six and nine hours, and that two 14 normal electrocardiograms in the presence of 15 ongoing pain and certainly one and maybe two sets 16 of enzymes were enough in this case. 17 Q. Well, you said, what, six to nine hours from 18 what? 19 A. Our usual protocol is probably zero, somewhere 20 between zero and nine. 21 Q. Okay. I'm sorry. In your protocol, when are the 22 cardiac enzymes done? 23 A. At presentation, at nine hours, and a second set 24 in between. 25 Q. Okay. 87 1 A. The reason I believe that myocardial ischemia and 2 the terminal event were not the case in Mrs. 3 Broncaccio is that people die of heart attacks 4 because of large, very obvious anterior wall 5 infarctions, or malignant ventricular 6 arrhythmias, none of which there was any evidence 7 to suggest occurred in her case. 8 Q. What would be evidence of a malignant ventricular 9 arrhythmia? 10 A. According to the records and the 11 electrocardiographic strip, she was hard wire 12 monitored the entire time. 13 Q. And what would a monitor show if there was a 14 sudden arrhythmic event? 15 A. There are alarms and prints that show that an 16 alarm fence has caused a print and a notation 17 that the rhythm is abnormal. 18 Q. Okay. 19 MS. REINKER: Doctor, I think I 20 may be pretty well finished. 21 Q. Are you intending to come to Cleveland to testify 22 live at the trial in March? 23 A. If need be, yes. 24 Q. Now, again, have we covered all of the opinions 25 that you are currently aware you will be 88 1 rendering at trial? 2 A. I think we have. 3 Q. By the way, if you asked a physician to complete 4 a record that you found to be incomplete, you 5 would expect that physician to date it the date 6 he or she wrote the correction, correct? 7 A. Yes. 8 Q. And that's what was done in this case? 9 A. There is a notation at the top of the seventh, 10 and then a notation at the bottom where he signed 11 of the date of the writing of the medical 12 records, which I think is appropriate notation. 13 Q. And again, we have now covered all the opinions 14 that you intend to be rendering at the trial of 15 this case? 16 A. I believe we have. 17 Q. And I would ask if you form any new opinions or 18 -- by the way, do you intend to review anything 19 else before the trial? 20 A. Not likely, unless somebody requests me to. 21 MS. REINKER: Is anybody going to 22 be requesting him to look at anything that 23 they know of now? Mark, Toby, are you 24 there? 25 MR. RUF: No, we still have 89 1 discovery that's outstanding. 2 MS. REINKER: But at the moment 3 you don't know of anything else you are 4 going to have him look at? 5 MR. RUF: At this moment, no. 6 There still are things we have not 7 received. 8 MS. REINKER: Well, you're talking 9 about the stuff the Court is deciding 10 about? 11 MR. RUF: Yes. 12 MS. REINKER: Okay, doctor. I 13 believe I am finished, and again, I would 14 ask if you form any new opinions to let 15 Mr. Hirshman or Mr. Ruf know about that so 16 I can depose you again before trial if need 17 be. 18 THE WITNESS: Okay. 19 MS. REINKER: Thank you. I am 20 hanging up now, guys. 21 MR. HIRSHMAN: Thank you, doctor. 22 MS. REINKER: Doctor, do you want 23 to read this transcript? 24 THE WITNESS: I would waive. 25 (Signature waived.) 90 1 2 C E R T I F I C A T E 3 4 The State of Ohio, ) SS: 5 County of Cuyahoga.) 6 I, Judith Gage, a Notary Public within and for the State of Ohio, authorized to administer 7 oaths and to take and certify depositions, do hereby certify that the above-named ROBERT A. 8 MULLIKEN, M.D. was by me, before the giving of his deposition, first duly sworn to testify the 9 truth, the whole truth, and nothing but the truth; that the deposition as above-set forth was 10 reduced to writing by me by means of stenotypy, and was later transcribed into typewriting under 11 my direction; that this is a true record of the testimony given by the witness, and the reading 12 and signing of the deposition was expressly waived by the witness and by stipulation of 13 counsel; that said deposition was taken at the aforementioned time, date and place, pursuant to 14 notice or stipulation of counsel; and that I am not a relative or employee or attorney of any of 15 the parties, or a relative or employee of such attorney, or financially interested in this 16 action. 17 IN WITNESS WHEREOF, I have hereunto set my hand and seal of office, at Cleveland, Ohio, this 18 _____ day of _________________ A.D. 2000. 19 20 _________________________________________________ 21 Judith Gage, Notary Public, State of Ohio 1750 Midland Building, Cleveland, Ohio 44115 22 My commission expires March 23, 2005 23 24 25 91 1 E X H I B I T I N D E X 2 EXHIBIT MARKED 3 Defendant's Exhibit A, Curriculum Vitae...................... 3 4 Defendant's Exhibit B, 5 Report of Robert Mulliken, M.D., undated.............................. 23 6 Defendant's Exhibit C, 7 Report of Robert Mulliken, M.D. dated 10/26/99 ...................... 23 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25