0075 1 IN THE COURT OF COMMON PLEAS 2 OF CUYAHOGA COUNTY, OHIO 3 - - - - - 4 LARRY ZERBIAN, et al., 5 Plaintiffs, 6 vs. Case No. CV-07-618652 7 UNIVERSITY HOSPITALS 8 HEALTH SYSTEM, INC., 9 et al., 10 Defendants. 11 - - - - - 12 DEPOSITION OF MATTHEW B. PAWLICKI, M.D. 13 THURSDAY, NOVEMBER 1, 2007 14 VOLUME II 15 - - - - - 16 The continued deposition of MATTHEW B. PAWLICKI, M.D., a Defendant herein, called by 17 the Plaintiffs for examination under the statute, taken before me, Cynthia A. Sullivan, a 18 Registered Professional Reporter and Notary Public in and for the State of Ohio, pursuant to 19 notice and stipulations of counsel, at the offices of Moscarino & Treu, The Hanna Building, 20 Suite 630, 1422 Euclid Avenue, Cleveland, Ohio, on the day and date set forth above, at 21 9:20 a.m. - - - - - 22 23 24 25 0076 1 APPEARANCES: 2 On behalf of the Plaintiffs: 3 Becker & Mishkind Co., LPA, by 4 HOWARD D. MISHKIND, ESQ. 5 Skylight Office Tower 6 1660 West Second Street 7 Suite 660 8 Cleveland, Ohio 44113 9 (216) 241-2600 10 11 On behalf of the Defendants: 12 Moscarino & Treu, by 13 JOHN T. BULLOCH, ESQ. 14 630 Hanna Building 15 1422 Euclid Avenue 16 Cleveland, Ohio 44115 17 (216) 621-1000 18 19 ---- 20 21 22 23 24 25 0077 1 MATTHEW B. PAWLICKI, M.D., of lawful age, 2 called for examination, as provided by the Ohio 3 Rules of Civil Procedure, being by me first duly 4 sworn, as hereinafter certified, deposed and 5 said as follows: 6 EXAMINATION OF MATTHEW B. PAWLICKI, M.D. 7 BY MR. MISHKIND: 8 Q. Even though I know who you are, to 9 make this a nice and neat transcript, would you 10 restate your name for the record. 11 A. Matthew Pawlicki. 12 Q. Dr. Pawlicki, we met on October 22nd 13 at which time we started the deposition, but it 14 was adjourned to give you the opportunity to 15 review additional records, and I presume that 16 you have had an opportunity to do so; is that 17 correct? 18 A. I have, yes. 19 Q. Tell me what you have reviewed by 20 way of medical records. 21 A. I reviewed the hospital records from 22 the admission dated 8-31-05 to 9-2-05 and then 23 9-4-05 to 9-5-05 at Geauga Hospital. 24 Q. After reviewing those records, it 25 became apparent to you that you were involved in 0078 1 various aspects of Mr. Zerbian's care; is that 2 correct? 3 A. Yes. 4 Q. After the second admission at Geauga 5 Hospital and then prior to January, did you have 6 any direct contact with Mr. Zerbian to your 7 knowledge? 8 A. No. 9 Q. After the January office visit that 10 we'll talk a little bit more about during 11 today's deposition, have you had any 12 communication with Mr. Zerbian since that date? 13 A. Not other than the phone call back 14 regarding his labs. 15 Q. Other than reviewing the hospital 16 records for the two admissions, have you 17 reviewed anything else by way of any literature 18 or medical records or medical reports that would 19 be pertinent or relevant to Mr. Zerbian? 20 A. This morning we reviewed some of the 21 blood work from his subsequent hospitalization 22 at UH Hospitals regarding the CBC. 23 Q. Tell me, which blood work or which 24 labs did you review? 25 A. They were CBC reports and ESR 0079 1 reports from, I don't know the exact date, but 2 9-6 through that next week or so. 3 Q. Did those labs provide you with any 4 information as it relates to the ultimate 5 diagnosis that was reached on Mr. Zerbian? 6 A. I don't think there's any conclusive 7 evidence regarding those labs. They were 8 variable and mostly nonspecific markers. 9 Q. The CBC and ESR? 10 A. Right. The ESR is a nonspecific 11 marker, and the CBC while on some days elevated 12 and some days normal is also affected by the 13 steroids, the corticosteroids, he was receiving. 14 Q. What was he receiving steroids for? 15 A. His lumbar back pain and muscle 16 spasm. 17 Q. Do you know what antibiotic regimen 18 he had been on prior to the CBC and ESR that you 19 reviewed from University Hospitals? 20 A. I don't believe we had him on any 21 antibiotic. 22 Q. Do antibiotics affect the 23 interpretation of a CBC as it relates to 24 identifying or isolating an infectious process? 25 A. I don't think an antibiotic has a 0080 1 direct effect on the CBC. 2 Q. What about blood cultures, do 3 antibiotics have an effect on the accuracy of 4 blood cultures in terms of diagnosing a 5 particular etiology for a condition? 6 MR. BULLOCH: A particular etiology? 7 MR. MISHKIND: In general. 8 MR. BULLOCH: A particular bug? 9 MR. MISHKIND: A particular bug, 10 yes. 11 A. I'm not a microbiologist, but I 12 believe the effect of using an antibiotic would 13 affect whether or not a culture became positive 14 but wouldn't change the -- I don't think it 15 would make a difference based on what bacteria 16 it was. 17 Q. Do you know whether certain 18 antibiotics given suppress various bugs and if 19 certain antibiotics are not continued whether or 20 not the suppression only continues so long as 21 that antibiotic is continued? 22 A. I believe the error comes with an 23 active use of the antibiotic, whether it's 24 antibiotics in the bloodstream inhibiting the 25 growth in culture of that bacteria. 0081 1 Q. If you have a Strep viridans that is 2 the bacteria in the blood, do you know what the 3 standard protocol is in terms of the antibiotic 4 and the length of treatment that one administers 5 to a patient that is symptomatic as well as has 6 positive blood cultures for Strep viridans? 7 A. I think I would have to know more 8 about the patient and know more about the 9 diagnosis and his health status. I think that 10 the direction of antibiotic treatment depends on 11 the susceptibility panel to guide the choice of 12 antibiotic unless you were using a broad 13 spectrum antibiotic prior to the susceptibility 14 results. 15 I'm not sure as far as the length of 16 treatment what kind of bacteremia we'd be 17 treating, a transient bacteremia or asymptomatic 18 bacteremia, or if it was symptomatic sepsis 19 which would be an active infection in the blood 20 with symptoms, I think there would be a period 21 of acute management followed by a longer 22 antibiotic course determined by the infectious 23 disease specialist. 24 Q. We talked last time when we met 25 about the multidisciplinary approach to either 0082 1 subacute bacterial endocarditis or infectious 2 endocarditis, and that sort of dovetails into 3 what I think you just said, that depending upon 4 the nature of the bug and the patient, 5 infectious disease is often consulted in terms 6 of the management of bacterial endocarditis; is 7 that true? 8 A. Yes. 9 Q. Now I want to ask you some questions 10 about the admissions and then the office visit, 11 and then hopefully we'll wrap things up. Since 12 you've had an opportunity to review the Geauga 13 records and to look at some of the labs from 14 University Hospitals, first, can we agree that 15 Mr. Zerbian was eventually diagnosed with 16 bacterial endocarditis? 17 MR. BULLOCH: If you know. 18 A. That is my understanding, but not 19 from any of the records that I've reviewed. 20 Q. Do you have an opinion as to when 21 the bacteria affected the heart, when he 22 developed the bacterial endocarditis prior to 23 the diagnosis of the same? First, do you have 24 an opinion? 25 MR. BULLOCH: Objection. 0083 1 A. I don't think I have an opinion. 2 Q. Do you have an opinion looking at 3 what you have looked at, and obviously this is 4 in retrospect because you were involved in 5 certain aspects of the care but after September 6 you weren't involved until January of the next 7 year with his treatment, but do you have an 8 opinion as to when treatment of his bacterial 9 endocarditis would have prevented the need for 10 any surgical intervention in terms of repair or 11 replacement of any heart valves? First, do you 12 have an opinion based upon your review? 13 MR. BULLOCH: Objection. 14 A. I don't think I can speculate on 15 when specific damage would be done. 16 Q. Have you reviewed enough information 17 from your records, Dr. Goddard's records, and 18 the hospital records to be able to arrive at any 19 opinions relative to the care that Mr. Zerbian 20 received between the September hospitalization 21 and prior to your seeing him, whether or not the 22 management of his symptoms and his findings, 23 whether or not the care met or fell below 24 accepted standards of care? Do you have an 25 opinion one way or another on that issue? 0084 1 A. I have no opinion based on review of 2 the laboratory tests. 3 Q. And the information that's been 4 available to you? 5 A. Right, the information that I've 6 reviewed. 7 Q. Okay. We talked about the Duke 8 criteria briefly in the last deposition for 9 diagnosing and treating infective or bacterial 10 endocarditis. Have you reviewed that, the Duke 11 criteria, between the time of our deposition a 12 week or so ago and today? 13 A. I have not. 14 Q. Have you reviewed any criteria for 15 minor or major symptoms or signs relative to the 16 diagnosis and treatment of infective 17 endocarditis? 18 A. I have reviewed criteria on the 19 upper limits of normal for erythrocyte 20 sedimentation rates, but not specifically with 21 regard to bacterial endocarditis. 22 Q. What did you review and what source 23 did you review in terms of the upper limits of a 24 normal or abnormal ESR? 25 A. From the textbook of the American 0085 1 Society For Arthritis, the range of normal was 2 given as a male patient's age divided by two as 3 the upper limit of normal for the ESR. 4 Q. Why did you choose that particular 5 textbook for your reference? 6 A. That was the textbook from my 7 medical training where I most intimately used 8 ESR testing for evaluation of inflammatory 9 arthritis and the workup. 10 Q. Is there a particular chapter that 11 has lab values in it in this textbook? 12 A. I think it may have been part of the 13 rheumatoid arthritis chapter. 14 Q. Give me the name of that book again, 15 please. 16 A. It is the textbook on Rheumatology 17 published by the American Arthritis -- either 18 the American Arthritis Foundation or American 19 Arthritis Society. 20 Q. Was this the most recent edition 21 that you looked at? 22 A. No. I'm sure it was from the late 23 '90s. 24 Q. Do you own a copy of that? 25 A. I do. 0086 1 Q. You refer to it on a regular basis? 2 A. On occasion. 3 Q. Do you consider the information 4 contained in that textbook from the American 5 Arthritis Foundation or Association as it 6 relates to lab values to be reasonably reliable? 7 A. I do, but I would not necessarily 8 agree to every sentence in the text. 9 Q. Sure. I'm not suggesting that we're 10 talking about every sentence. We're talking 11 about the aspects as it relates to the 12 interpretation of and the significance of 13 perhaps lab values and most specifically 14 erythrocyte sedimentation rates. You consider 15 that reasonably reliable? 16 A. I do. 17 Q. Do the lab values or the range of 18 normal values from that book differ from the 19 normal values that were set by the hospital, 20 Geauga Hospital, for what was considered to be 21 the upper limit of normal? 22 A. Yes, and I do not -- I cannot say 23 whether the hospital range of normal took into 24 consideration patient age. 25 Q. If a lab value is indicated as 0087 1 abnormal by a hospital, in particular Geauga 2 Hospital, do you ignore that abnormal value if 3 in fact it is different from what you've read in 4 the American Arthritis Foundation textbook? 5 A. I don't ignore it, but I take it 6 into consideration and apply my clinical 7 judgment and personal experience. 8 Q. Let's talk about the admission of 9 September 4 -- I'm sorry, the admission of 10 August 31. 11 A. Okay. 12 Q. You were the admitting physician for 13 that admission? 14 A. I believe Dr. Goddard gave admission 15 orders, and I saw the patient for the admission 16 note the following morning. 17 Q. What was his chief complaint that 18 caused his admission? Again, during my 19 questioning, please feel free to refer as you 20 are right now to the hospital chart. 21 A. The chief complaint was back pain. 22 Q. There's a reference to intractable 23 back pain? 24 A. Intractable is a qualifier I think 25 he earned in the emergency room when he was not 0088 1 able to be sent home on an ambulatory basis with 2 the acute treatment. 3 Q. When did you first see him on 4 admission? 5 A. My admission note is dated 6 8-31-2005, and the time of dictation is not 7 listed, but my habit was to round in the 8 morning. 9 Q. On the admission note I have, I 10 think there actually is a time of 8:00 a.m., 11 8:08 if you look at the second page. 12 A. Oh, perfect, yes. 13 Q. So that would be consistent with 14 what you would do? 15 A. Yes. 16 Q. To your knowledge is this the first 17 time that you had ever met Mr. Zerbian? 18 A. I believe so, but there have been 19 cases where I did not remember him previously, 20 so I think this was the first time I'd met him. 21 Q. When you say there have been cases, 22 you mean our get-together a week ago? 23 A. Our get-together, yes. 24 Q. Do you believe that having reviewed 25 the records now that you have sufficient data in 0089 1 front of you to be able to say more likely than 2 not that this is the first time that you met 3 Mr. Zerbian? 4 MR. BULLOCH: If that's not the 5 case, Howard, I trust you're going to put a 6 couple pieces of paper in front of him. 7 A. Right. I don't think I have 8 mentioned in here that this is the first time 9 I've seen him, but I don't think I had seen him 10 prior to this. 11 Q. Looking at the admission note and 12 looking at some of your notes in the chart, do 13 you have any recollection of Mr. Zerbian, an 14 independent recollection, either by being able 15 to paint a picture in your mind of him or to 16 have any sort of summary or overview in your 17 mind of this particular patient? 18 A. No. There is nothing. From reading 19 these I have no further recollection to 20 distinguish him from the many other patients 21 with back pain that I treat regularly. 22 Q. At the time of his admission, did he 23 have an elevation in his white blood count? 24 A. From the labs on 9-1-2005, his white 25 blood count was normal. 0090 1 Q. For the record, what was his white 2 blood count? 3 A. 10.7. 4 Q. And the hospital range for the upper 5 limit of normal? 6 A. The upper limit of normal is 11.3. 7 Q. Do you accept that as a reasonable 8 upper limit of normal? 9 A. I do. 10 Q. During your examination of 11 Mr. Zerbian, did you detect any heart murmur or 12 any shortness of breath during the physical 13 exam? 14 A. I did not. 15 Q. Did you obtain any history of any 16 prior valvular problems that Mr. Zerbian had? 17 A. In review of his past medical 18 history, no prior valvular problems presented. 19 Q. How many times did you see 20 Mr. Zerbian in that hospital admission? 21 A. In the morning of 8-31-05 is one, 22 the morning of 9-1-05 is two, and then on the 23 day of discharge, 9-2-05, is three. 24 Q. I'm going to show you what has been 25 marked previously from October 22nd as 0091 1 Plaintiff's Exhibit 5. Is this a copy of the 2 discharge summary that you prepared relative to 3 Mr. Zerbian's admission? 4 A. Yes. 5 Q. During the admission were there any 6 other physicians that were seeing Mr. Zerbian 7 other than yourself? 8 A. Yes. The hospitalist who did his 9 initial H&P saw him between his admission and 10 when I saw him in the morning, and that is 11 Steven Gyurgyik. 12 Q. How does Dr. Gyurgyik spell his last 13 name? 14 A. G-Y-U-R-G-Y-I-K. The emergency room 15 physician who admitted him or evaluated him and 16 then Dr. Shall, the orthopedic surgeon we 17 consulted. 18 Q. The name of the emergency room 19 doctor that saw him, could you give that to me 20 please just for the record? 21 A. Amy Allegretti, A-L-L-E-G-R-E-T-T-I. 22 Q. Did you consider an infectious 23 source as being a potential cause of his back 24 pain? 25 A. I did not. 0092 1 Q. A differential sometimes is, and 2 correct me if I'm wrong, things that you will 3 consider but not necessarily put down as an 4 ultimate diagnosis; is that a fair statement? 5 A. Yes. It would be a list of 6 diagnoses that would be considered in the 7 process of coming to the final diagnosis. 8 Q. Within your differential you 9 wouldn't necessarily mark down everything that 10 you have in your mind, but you'd work up the 11 patient for clinical symptoms, do certain tests, 12 and try to arrive at the most likely diagnosis; 13 true? 14 A. True. 15 Q. In working the patient up before the 16 final diagnosis was arrived at, can you tell me 17 what you most likely had within your 18 differential before arriving at your final 19 diagnosis? 20 MR. BULLOCH: Objection. You can 21 answer if you can. 22 A. Okay. Based on my dictated note, I 23 was -- my primary diagnosis or working diagnosis 24 was muscle spasm, and then I explicitly 25 mentioned no signs of radiculopathy or nerve 0093 1 root impingement. Then our further CT scan was 2 used to rule out some other possible causes such 3 as fracture or disk disease or I guess to 4 clarify it more specifically as to the cause. 5 Then the results of the lumbar spine 6 X-ray and the CT scan sort of brought through 7 some diagnoses such as spondylosis and 8 degenerative changes, and there was always the 9 possibility of a herniated disk as the cause of 10 this. 11 Q. What is diskitis? 12 A. It is inflammation of the 13 intervertebral cushioning disk of the spine 14 between each -- there is a disk between each 15 vertebra, so inflammation in that disk space, 16 soft tissue space. 17 Q. What are some of the more common 18 causes that you as a family practice physician 19 encounter in treating a patient for diskitis? 20 A. I'm not sure I understand the 21 question. What causes diskitis? 22 MR. BULLOCH: Let him reask it. 23 Q. You put it better than I did 24 initially. What causes diskitis? What are the 25 common causes that you encounter? 0094 1 A. I must say I rarely encounter 2 diskitis as a cause, and I often in my rationale 3 kind of keep it together in my mind with 4 osteomyelitis and the differential of back pain 5 or bone pain. 6 Q. Is it fair to say that in diskitis 7 or osteomyelitis you would be considering, if in 8 fact that was your potential diagnosis, you 9 would be considering infection as a potential 10 source in that hypothetical setting? 11 MR. BULLOCH: Objection. 12 THE WITNESS: Objection, do I have 13 to answer? 14 MR. BULLOCH: Yes. 15 Q. Just so you're clear again, if 16 there's an objection, it's for the record, and 17 obviously any question I ask of you, if you 18 don't know the answer, just tell me you don't 19 know, and if you need something clarified, ask 20 me to clarify it. 21 A. Repeat the question. 22 Q. Sure. I'm dealing in a hypothetical 23 situation where you have a patient where you are 24 considering whether or not the patient has 25 diskitis or osteomyelitis. Are either of those 0095 1 conditions potentially caused by some infection 2 that gets into either the disk space or the dura 3 and somehow affects the lumbar area? 4 A. In a hypothetical patient, the 5 diskitis or osteomyelitis could be caused by a 6 bacterial infection, but in this patient there 7 was no sign or symptom to suggest a bacterial 8 infection. 9 Q. Was that within your differential 10 but ruled out based upon the workup, or did you 11 not have diskitis or osteomyelitis within your 12 differential on this patient? 13 A. If diskitis or osteomyelitis was 14 within my differential, it was ruled out by the 15 fact that he had a normal white blood count and 16 no evidence of bony or soft tissue inflammation 17 on CT scan. 18 Q. The fact that he didn't have a heart 19 murmur and didn't have any shortness of breath 20 on examination, what if anything did that tell 21 you? 22 A. Generally, heart murmurs and dyspnea 23 are not part of my expected findings for 24 diskitis or osteomyelitis. 25 Q. Did that give you some reasonable 0096 1 comfort that if he had an infection that at that 2 time there was no evidence that the infection 3 was affecting the heart or the valves to the 4 heart? 5 MR. BULLOCH: Objection. You can 6 answer. Unless I instruct you not to answer, 7 you can answer as long as you understand the 8 question. 9 A. Are we still on the hypothetical 10 patient? 11 Q. Sure. 12 A. Please, repeat the question. 13 Q. The fact there was no heart murmur 14 and no shortness of breath, and not in a 15 hypothetical patient but in this particular 16 patient, what did that permit you to rule out in 17 your mind at the time of your examination of 18 Mr. Zerbian? 19 A. I think in and of themselves, the 20 lack of a heart murmur and lack of respiratory 21 distress are overall reassuring. I don't think 22 in and of themselves they would without taking 23 the rest of the clinical picture into 24 consideration affect any of my medical judgment. 25 Q. If the patient did have bacterial 0097 1 endocarditis back in August, would you expect to 2 have heard some type of heart murmur on 3 auscultation of the heart? 4 A. I would expect that a patient who I 5 suspected to have bacterial endocarditis would 6 have a heart murmur. 7 Q. Was Mr. Zerbian clinically improved 8 at the time of his discharge? 9 A. Yes. 10 Q. The final diagnosis at the time of 11 discharge, he carried what as his final 12 diagnosis? 13 A. The primary diagnosis, probably 14 temporally incorrect at that point, was 15 intractable back pain which was his admitting 16 diagnosis and a secondary diagnosis of diabetes. 17 Q. I asked you a moment ago whether or 18 not he was improved, and you said that he was 19 improved. The reference to intractable back 20 pain at the time of the discharge summary would 21 suggest that his pain was not resolving, 22 correct, if one were to correctly use the term? 23 A. Correct. I think based on the body 24 of my hospital course I would say that my choice 25 of intractable back pain as his primary 0098 1 discharge diagnosis is inaccurate. 2 Q. If you were to amend this chart 3 summary to have the primary diagnosis accurately 4 reflect his clinical condition at the time of 5 discharge, what would you now put as the primary 6 discharge diagnosis for that admission? 7 A. Acute -- probably acute lumbar back 8 pain and muscle spasm and degenerative 9 arthritis. 10 Q. There were homegoing instructions 11 given for this admission of August 31, 2005, 12 which I believe you signed? 13 A. Yes. 14 Q. I want to go over the medications 15 that you had prescribed. The first, is that 16 Glucophage? 17 A. That is Glucophage. 18 Q. That's for his diabetes? 19 A. It is. 20 Q. What was also prescribed? I'm 21 having a difficult time deciphering it. 22 A. There are three diabetes 23 medications; Glucophage, Amaryl and Actos, and I 24 will point out I guess a verbal 25 during-the-dictation error where I substituted 0099 1 Avandia for Glucophage, and I suspect that I had 2 intended to say Glucophage due to the fact that 3 Actos and Avandia are very similar medications 4 and would be redundant. 5 Q. Right before the Glucophage, what is 6 that word? 7 A. Resume. 8 Q. You also prescribed Percocet? 9 A. Yes. 10 Q. The Percocet was for the pain? 11 A. Every four hours for pain. 12 Q. Valium was crossed out. Why was it 13 written, and why was it crossed out? 14 A. I don't have explicit documentation 15 why it was crossed out. In the assessment and 16 plan on my handwritten note, his discharge pain 17 medications did not include the Valium, so I may 18 have accidentally written it and then amended 19 it. 20 Q. The next homegoing medication was 21 ibuprofen; is that correct? 22 A. It is. 23 Q. Then the Medrol dose pack, that's 24 the corticosteroid? 25 A. Yes, it is. 0100 1 Q. The reason that was prescribed along 2 with the ibuprofen and the Percocet, can you 3 explain that to me? 4 A. It's an anti-inflammatory which can 5 relieve some of the soft tissue pressure in the 6 back. 7 Q. And Soma? 8 A. Soma is a muscle relaxant, and it 9 was prescribed for spasm. 10 Q. The homegoing instructions are two 11 pages; correct? 12 A. Yes. 13 Q. Do you recall discussing 14 Mr. Zerbian's care with Dr. Shall while he was a 15 patient at the hospital? 16 A. I do not recall any conversations 17 aside from my documentation in the progress 18 notes and order forms. 19 Q. In fact, I'm going to show you just 20 because I marked it, and if I mark something, I 21 want to have it as part of the record, three 22 pages. It's marked as Plaintiff's Exhibit 6. 23 The first page is an abstract 24 summary from the Geauga Hospital record that I'm 25 sure was not prepared by you, but it has 0101 1 diagnosis codes, and then pages 2 and 3 of that 2 exhibit are the homegoing instructions that we 3 just discussed. 4 A. Yes. 5 Q. Did I accurately describe that? 6 A. It is, but this is -- the summary 7 abstract is I think for hospital billing 8 purposes the summary of diagnoses. 9 Q. As you look at the diagnoses, 10 whether they are for billing purposes or 11 otherwise, do you have any reason to dispute the 12 codes or the diagnoses that are typed on this 13 patient? 14 A. The -- I'm -- I would agree with 15 these. I'm just not sure. I assume the DM II 16 is Type II diabetes without complications. I'm 17 not sure what the NT and the ST refer to, and 18 the uncontrolled, I'm not sure why the 19 uncontrolled is there because the diagnosis code 20 of 250.00 is for Type II diabetes which is 21 controlled. 22 Q. So with regard to that document that 23 is the face sheet of Exhibit 6, there is at 24 least some inconsistency between the billing 25 code and the reference to uncontrolled diabetes 0102 1 thereafter; is that correct? 2 A. Yes. 3 Q. Did you consider his diabetes during 4 the hospitalization to be controlled? 5 MR. BULLOCH: Doctor, again, take a 6 look at whatever records you need to to make 7 that determination. We all understand you don't 8 remember this patient and you don't remember 9 this admission, so make sure you're listening to 10 his question and you're answering it on the 11 basis of your review of the medical records as 12 we sit here today. 13 Q. You understand that, and we don't 14 have to repeat that warning or precaution to 15 you. You take your time, you look at the 16 records, and if you don't know an answer, you 17 can tell me you don't, but if you need to study 18 the records for three hours, you go ahead and do 19 it. 20 A. Based on his blood sugar readings 21 while he was in the hospital, he did have 22 elevated blood sugars which I attributed to the 23 IV steroids, and he did show good baseline 24 control due to his fasting blood sugars which 25 were under control in the morning. 0103 1 So we had not unusually variable 2 data, so sometimes it appeared to be fairly well 3 controlled and at others elevated due to the 4 corticosteroids. 5 Q. In treating a patient that has an 6 infection, does the status of the patient's 7 diabetes being controlled or uncontrolled impact 8 the potential course of that infection in a 9 hypothetical patient? 10 A. The recommendations, the general 11 recommendations, are to keep as good of control 12 as possible on a patient's blood sugar. I'm not 13 sure if it's specifically for infectious reasons 14 or general metabolic reasons, but the 15 recommendations that I've heard recently have 16 been for tighter control rather than laxer 17 control. 18 Q. Do you have an understanding as a 19 physician as to why it is that a patient that 20 you suspect has an infection or in fact may 21 hypothetically have an infection, why it's 22 important to maintain good control over their 23 diabetes? 24 A. Well, I think there's two 25 considerations that I understand with regard to 0104 1 blood sugar control and infection, that 2 infections -- the presence of an infection can 3 cause blood sugars to be poorly controlled 4 raising the need to step up controlling efforts, 5 and then poorly controlled diabetics are more 6 prone to certain bacterial infections such as 7 UTI, urinary tract infections, due to the 8 glycosuria and oftentimes yeast infections I've 9 seen a lot of. 10 But more specifically than that I 11 don't think I can comment. Those are my general 12 concerns with regard to elevated blood sugars 13 and infection. 14 Q. What is the definition of 15 endocarditis? 16 A. Endocarditis is an inflammation of 17 the inner lining of the heart organ. So 18 distinguishing it from myocarditis which would 19 be the central muscle, this would be the lining 20 of the blood vessels inside the heart. 21 Q. Why do patients that develop 22 endocarditis typically have valvular 23 involvement? 24 A. The heart valves are within, or I'm 25 not sure if I'm correct anatomically speaking, 0105 1 are lined by the endocardium or within the 2 endocardial space. 3 Q. If you know, are diabetic patients 4 that have a particular bacteria circulating in 5 their body more susceptible to developing 6 endocarditis than -- strike that. 7 Are uncontrolled diabetics more 8 susceptible to developing endocarditis from a 9 particular bacteria than controlled diabetics, 10 if you know? 11 A. I do not know that. 12 Q. I want to now move from this 13 hospitalization. Were you the attending for the 14 next admission which would be the September 4 15 admission, I believe? 16 A. I was the attending who accepted the 17 admission. 18 Q. Were you accepting this admission on 19 behalf of Dr. Goddard? 20 A. On behalf of our group practice. I 21 think I was on call that night, and due to me 22 being the attending on the previous admission I 23 think is how I became the attending, but yes. 24 Q. I'm going to show you, again more 25 for identification purposes than anything else, 0106 1 Plaintiff's Exhibit 7. I will describe what 2 this is and hand it over to you so you can 3 confirm it, but it appears as if this is the 4 emergency room record, emergency department 5 record, for that admission which includes the 6 physician's record, the nursing notes, and then 7 the emergency department patient nurse's notes. 8 It is four pages in length. 9 If you could, just take a look at 10 that and confirm that what I've identified is in 11 fact accurate. 12 MR. BULLOCH: Howard, just for the 13 record, just note that the dictated summary of 14 the emergency room physician is not included in 15 that, but other than that, it appears to be 16 complete. 17 Q. Doctor, other than a dictated 18 summary, does that appear to be the emergency 19 room record? 20 A. Yes. 21 Q. On the front sheet it indicates 22 admit to Pawlicki, consult Shall, and then next 23 to that notified. Is that your handwriting, or 24 is that the emergency room doctor's handwriting 25 to your knowledge? 0107 1 A. That would be the emergency room 2 doctor's handwriting. 3 Q. It appears that the emergency room 4 doctor was suggesting an admission under your 5 service with Dr. Shall as the orthopedic 6 consultant; is that a fair statement? 7 A. It is. 8 Q. For intractable back pain? 9 A. It is. 10 Q. Did you actually see Mr. Zerbian in 11 the emergency room? 12 A. I did not. 13 Q. Mr. Zerbian was transferred from 14 Geauga Hospital to University Hospitals at the 15 end of this particular admission; is that 16 correct? 17 A. It is. 18 Q. From review of the records, can you 19 tell me as best you can recollect and again from 20 the written record why there was a transfer of 21 the patient from Geauga Hospital to University 22 Hospitals? 23 MR. BULLOCH: Howard, just let me 24 note that I think Dr. Pawlicki has already said 25 he never saw the patient during this entire 0108 1 admission. He didn't see him there, and I don't 2 believe he saw him at any time during this 3 admission. So any comment that he's offering 4 isn't based on his note or his recollection but 5 solely based on the records of other physicians. 6 MR. MISHKIND: Well, I'm not sure 7 that that's what he testified to. That is 8 perhaps what you clarified as to what he might 9 testify to, John. I certainly appreciate that. 10 Q. Doctor, you understand if I imply 11 something or state something that's not 12 accurate -- 13 A. Okay. 14 Q. -- you correct me. 15 A. Okay. 16 Q. That's what I want. You and I are 17 having this discussion, and I want you to 18 correct me if I say something wrong. 19 Did you see this patient in the 20 admission of September 4, 2005? 21 A. I did not. 22 Q. The history and physical that was 23 dictated has your name on it, but it's signed by 24 Dr. Barboza, B-A-R-B-O-Z-A; is that correct? 25 A. That is. 0109 1 Q. Who is Dr. Barboza? 2 A. Dr. Barboza is or was the 3 hospitalist at Geauga Hospital and would 4 sometimes do the admit H&P on patients admitted 5 until we could get into the hospital or a 6 covering physician could get into the hospital. 7 Q. Is Plaintiff's Exhibit 8 a copy of 8 that history and physical that Dr. Barboza 9 prepared? 10 A. It is. I'm just missing my copy 11 here. 12 Q. You can refer to that, and I'm not 13 going to have a lot of questions relevant to 14 that. 15 A. Yes. This is the one. 16 THE WITNESS: May I ask for a quick 17 break? I'll be right back. 18 MR. MISHKIND: You need to take a 19 break? That's fine. 20 (Brief recess.) 21 Q. Doctor, what you have in front of 22 you which is a dictated history and physical 23 examination by Dr. Barboza is Plaintiff's 24 Exhibit 8; is that correct? 25 A. Yes. 0110 1 Q. Given that you were the physician 2 that was contacted for the admit through the 3 emergency room department, can you explain to me 4 why it is that you did not see this patient 5 during this admission? 6 A. I believe Dr. O'Hara was the 7 covering physician who saw him on 9-4-05 and 8 also discharged him. 9 Q. That's Dr. Janet O'Hara, the 10 internal medicine doctor in your group that we 11 talked about when we went through the inventory 12 of players? 13 A. Yes, internal medicine and 14 pediatrics. 15 Q. Were you out of town, or do you know 16 why it was that you didn't participate other 17 than the fact that Dr. O'Hara was on call? 18 A. I don't recall if I was out of town, 19 but our customary practice is to have the 20 on-call physician for the weekend or for the 21 evening manage the hospital patients. 22 Q. Does the record indicate from your 23 review that there was any communication between 24 Dr. O'Hara and you? 25 The reason I ask that is given the 0111 1 fact that you had been involved in his admission 2 a few days earlier and the admit was under your 3 name, does it indicate that there was any 4 communication in any manner between you and Dr. 5 O'Hara? 6 A. I don't believe so. 7 Q. Prior to -- 8 A. Well -- 9 Q. Go right ahead. 10 A. I will take back that I would have 11 to -- since I was on call the night when we 12 admitted him and provided admission orders, I 13 would have discussed with Dr. O'Hara the sign 14 out and notify her that she would need to round. 15 Q. The sign out being, can you put that 16 into simple terms for a simple mind? 17 A. Right. So to get a feel for when 18 the time frame that this is going on that I was 19 -- I don't think -- I think that he may have 20 dictated this a significant time later than when 21 he was seen because I have Dr. O'Hara's -- well, 22 maybe not. 23 Oh, that is strange because 24 Dr. O'Hara had done the admission note and 25 subsequently Dr. Barboza did the H&P dictation, 0112 1 so those times probably are correct. It's at 2 7:22 in the evening, so it looks like from the 3 emergency room record that I was called in the 4 afternoon. 5 I would have left my orders with the 6 nursing staff there and then between that 7 afternoon and that evening spoken with 8 Dr. O'Hara. I'm guessing this was probably a 9 Friday afternoon, so we would have been in the 10 office together, and I would have told her that 11 this patient was being admitted. 12 I suspect that two years ago I would 13 have remembered an admission two days prior and 14 would have filled her in on what was going on. 15 Q. Is it fair to say that if that 16 exchange took place that you would have told her 17 that he had been in the hospital initially with 18 intractable back pain, a diabetic, that he had 19 been on the Medrol dose pack, had various blood 20 sugar medications, he had medication for muscle 21 spasm as well as inflammation and had been 22 discharged to follow up with Dr. Goddard and was 23 back in the emergency room with further 24 intractable back pain or something to that 25 effect? 0113 1 A. Yes. 2 MR. BULLOCH: Are you testifying, 3 Howard, or is there a question there? 4 MR. MISHKIND: That was a question 5 there, and he just answered it. 6 MR. BULLOCH: Okay. 7 Q. The orders that you said that you 8 would have given, what orders were they? 9 A. The physician orders. On 9-4-05 at 10 2:35 I spoke with the nurse, and the TO is for 11 telephone order, to admit to my service and 12 consult Dr. Shall. 13 The floor, and this is the next line 14 which is floor to call for orders means that we 15 would get the patient to his room as fast as 16 possible, and then the nurses on the floor would 17 contact me for further orders. Diagnosis is 18 intractable back pain. 19 And then Dr. O'Hara signed those 20 orders in my stead, I would assume, that evening 21 when she got into the hospital. 22 Q. What time were the verbal orders? 23 A. 1435. 24 Q. Did those verbal orders include 25 doing routine labs? 0114 1 A. The routine labs would be part of 2 the further orders once they got to the floor, 3 and that's the next page. 4 Q. Were those your routine orders? 5 A. These, they are not routine orders. 6 Oh, I see what you mean. On number four, the 7 vital signs were circled routine, and I believe 8 routine was Q shift, every 8-hour shift at 9 Geauga Hospital. 10 Q. The normal process in terms of 11 admitting a patient from the emergency room is 12 for the emergency room doctor to provide the 13 admitting physician such as yourself all 14 information relative to labs and findings that 15 were available at the time that the admission is 16 being requested; correct? 17 A. In general, yes. 18 Q. There were labs that were drawn, a 19 CBC and chem panel, in the emergency room on 20 September 4, '05. Were you advised of the 21 results of those labs at that time? 22 A. I suspect I was not. It's in the ER 23 progress note that it is documented that labs 24 are pending at this time. 25 Q. Would that then be something that 0115 1 would be communicated and followed up as 2 necessary by Dr. O'Hara who, if your 3 recollection is correct, you would have talked 4 to in the office and passed the admission off to 5 her? 6 A. If it was not something that was 7 included in my sign off. It's our standard 8 practice to review laboratory results on our 9 patients that are admitted, and those are all -- 10 the emergency room labs are brought and part of 11 the regular chart in the hospital. 12 Q. Let me show you Plaintiff's 13 Exhibit 10 which looks like it was faxed to you 14 as well as made a part of the hospital chart, 15 and the reason I say that is Exhibit 10, can we 16 agree that Exhibit 10 is a printout of the labs 17 that had been collected in the emergency room 18 prior to Mr. Zerbian's admission? 19 A. Yes. 20 Q. Do you see at the bottom of that 21 page where it appears that the information, and 22 I may be wrong in terms of referring to it as 23 being faxed, but it has your name on it, and 24 maybe you can even tell me what that designation 25 at the very bottom of the sheet means. 0116 1 A. The last page of the report or the 2 absolute neutrophil? 3 Q. Right above where it says last page 4 of the report. 5 A. Oh, I'm sorry. So I think this just 6 reflects this is the patient, his ID number, and 7 I'm on the records as the attending and the 8 admitting physician. 9 Q. His white blood count, his WBC, was 10 elevated at the time that he was admitted to the 11 emergency room; correct? 12 A. It was. 13 Q. That was a change from his prior 14 admission several days earlier; correct? 15 A. Yes, consistent with the use of 16 corticosteroids. 17 Q. Could you rule out infection based 18 upon his WBC and his use of corticosteroids? 19 A. In the setting of a patient with 20 acute back pain who has been on several days of 21 corticosteroids from the previous admission and 22 a relatively modest white blood count elevation, 23 I think infection is less likely. 24 Q. Let me take the whole package 25 together. We've got an elevation in the sed 0117 1 rate to 29; correct? 2 A. Correct. 3 Q. That's higher than what his sed rate 4 had been on the previous admission; correct? 5 A. Correct. 6 Q. If we take the sed rate, the WBC, if 7 we want to look down through the absolute 8 neutrophils, there were a number of markers on 9 the panel that was taken in the emergency room 10 that would be consistent with infection; 11 correct? 12 MR. BULLOCH: Objection. 13 A. These blood test results would be 14 consistent with many patient states either from 15 medication changes or disease states, and at the 16 time he had no sign of infection -- no sign of 17 elevated temperature or fever. 18 Q. Going back to my question, though, 19 I'm not suggesting that these labs would make 20 one conclude without further evaluation that the 21 patient has an infection, but are these labs 22 consistent with an infectious process as a 23 potential diagnosis? 24 MR. BULLOCH: Objection. Asked and 25 answered. You can answer it again, Doctor. 0118 1 A. I think among many possible 2 explanations, an elevated white count and sed 3 rate is possible -- or is possible with 4 infection. 5 Q. There were other markers that were 6 high as well that would be consistent with but 7 not necessarily diagnostic of infection; 8 correct? 9 A. Well, the other markers, the 10 neutrophil count, all of that is essentially a 11 subset of the white blood count, so I don't 12 think that would be an independent indication. 13 Q. I'm sorry. I didn't want to 14 interrupt you. I mean taking into account the 15 sed rate, the white blood cell count, the 16 neutrophils? 17 A. Right. The neutrophil count is sort 18 of a qualification of the white blood count. 19 So, yes, the abnormal sedimentation rate, the 20 abnormal white blood count are two markers, and 21 then the differential qualifier of the white 22 blood count is seen both possibly from the 23 corticosteroids as well as infection. 24 Q. Thank you. Is it fair to say that 25 one could not exclude infection in Mr. Zerbian 0119 1 simply because he had been on corticosteroids in 2 looking at these lab results? 3 MR. BULLOCH: And only those lab 4 results, Howard? 5 Q. Do you understand my question, 6 Doctor? 7 A. I think you're asking solely with 8 one single blood test could you exclude -- 9 Q. Could you exclude -- 10 A. -- an entire range of infectious 11 diagnoses. I don't think such a clearcut 12 conclusion can be made from a single blood test 13 in any situation and would require a full 14 evaluation of the patient including the rest of 15 his clinical picture. 16 Q. Sure. My question wasn't intended 17 to be more difficult than perhaps it was made on 18 the opposite side of the table here, but based 19 upon these labs and the fact that the patient 20 was on corticosteroids, can we agree that one 21 could not exclude infection as a potential cause 22 for the abnormalities, not necessarily arrive at 23 a diagnosis of infection, but one could not 24 exclude from the differential infection as a 25 potential cause for these abnormal labs? 0120 1 MR. BULLOCH: Objection to form. 2 Q. Is that correct? 3 A. That is correct. 4 Q. Do the records reflect that 5 Dr. O'Hara consulted with you at all relative to 6 the discharge, or to make it real simple, is it 7 once you had this likely conversation with her 8 in the office that the decision-making then 9 relative to transfer as well as treatment 10 modalities was outside of your control? 11 A. Oh, I'm sorry. Do you mean that 12 once I signed out for the weekend, was there any 13 further discussion of the case until after he 14 was discharged? Please, repeat that question. 15 Q. Sure. You saw Dr. O'Hara in the 16 office most likely, and you gave her the 17 information. She then became the attending 18 because she was on call for that weekend; true? 19 A. True. 20 Q. After that point in time, do you 21 have any reason to believe that you had any 22 involvement at all in the decision-making as it 23 relates to the treatment of Mr. Zerbian at 24 Geauga Hospital? 25 A. No. 0121 1 Q. Do you have any reason to believe 2 that you had any involvement as it relates to 3 the decision-making concerning the transfer of 4 Mr. Zerbian from Geauga to University Hospital? 5 A. No. 6 Q. In your experience, is a positive 7 blood culture considered a critical lab value? 8 A. Boy, critical, what do you mean by 9 critical? 10 Q. Did you look in preparing for the 11 deposition to that American Arthritis 12 Association book on labs as it relates to what 13 is high, low, critical and the explanation from 14 a laboratory standpoint? 15 A. No. I didn't consult that book. 16 Q. In your experience as a family 17 practice physician, when you see a lab result 18 that has a C next to it, critical, what does 19 that mean to you? 20 A. A C with critical often is the 21 distinction between on a laboratory basis 22 whether we are called immediately with that 23 result and given verbal report prior to the 24 printout coming out or being faxed to us or not, 25 and so the C from the laboratory is based on 0122 1 cutoffs and based on severity. 2 As far as the importance of any 3 critical result, I think it would still depend 4 on the clinical setting and the evaluation of 5 the patient at the time. 6 Q. If you have a patient who has a 7 positive blood culture, do you consider that to 8 be something that needs to be followed up on? 9 A. It depends on the circumstances of 10 the culture, the number of cultures, the 11 bacteria identified, and the susceptibility, 12 yes. 13 Q. When a patient has a positive blood 14 culture, what is your normal course of action? 15 With one positive blood culture, what is your 16 normal course of action? 17 A. I don't think I have a normal course 18 of action independent of the patient, my 19 differential diagnosis, and the clinical 20 setting. 21 Q. If the patient has a positive 22 culture in one bottle, do you normally repeat 23 the test? 24 A. It depends on how many of the set 25 were taken, and certainly pediatric blood 0123 1 cultures are often done just once due to lack of 2 blood. Usually adults get two or more blood 3 cultures at a time. 4 Q. If one of two blood cultures in an 5 adult, and last time I looked Mr. Zerbian was an 6 adult, if one of two blood cultures are 7 positive, do you normally repeat the test? 8 MR. BULLOCH: Objection. Asked and 9 answered. 10 A. A one out of two positive blood 11 culture raises the suspicion or likelihood of 12 contamination depending on the bacteria that was 13 identified, depending on if the patient is ill 14 or gives reason for further workup. 15 In a septic patient who is showing 16 clinical signs, certainly. In a patient who 17 could have transient bacteremia after brushing 18 their teeth, it may not warrant further blood 19 culturing. 20 Q. Doctor, can you rule out bacteremia 21 versus contamination based on one set of 22 positive blood cultures and one negative set? 23 A. With just one positive and one 24 negative, I don't think you can rule out 25 bacteremia. 0124 1 Q. Can you rule out bacteremia if all 2 blood cultures are negative? 3 A. I would generally take the finding 4 that all blood cultures are negative as a fairly 5 good sign that there's no bacteremia. 6 Q. Does the organism that's isolated in 7 the culture impact your decision whether to 8 repeat blood cultures? 9 A. Yes. 10 Q. Did Mr. Zerbian to your knowledge 11 have an elevated temperature at any time during 12 his admission to Geauga Hospital for the second 13 admission? 14 A. Not that I saw. 15 Q. Do you need to have an elevated 16 temperature in the face of an elevated white 17 blood count, elevated C-reactive protein, 18 elevated erythrocyte sedimentation rate to 19 consider bacteremia within your differential? 20 MR. BULLOCH: Howard, are you 21 discussing a hypothetical patient now? We keep 22 bouncing back and forth, and I'm confused. Is 23 this a hypothetical patient or anybody in 24 particular? 25 MR. MISHKIND: We can take it as a 0125 1 hypothetical. 2 A. I don't think we had a C-reactive 3 protein on Mr. Zerbian. 4 Q. Let me help you out with this 5 question because you look like you're 6 struggling. 7 A. Right, please. 8 Q. Let me help you out. In a 9 hypothetical patient that has an elevated white 10 blood cell count, an elevated erythrocyte 11 sedimentation rate, and an elevated C-reactive 12 protein that doesn't have a temperature, can you 13 rule out bacteremia as a source of the patient's 14 condition? 15 MR. BULLOCH: Objection to form. 16 A. As far as back pain, I would not 17 look to bacteremia as being a significant cause, 18 and the general state that we worry about being 19 caused by bacteremia is sepsis which usually is 20 characterized by either a high temperature or 21 fever or sometimes a very -- a low temperature, 22 but generally involves an acutely ill patient. 23 So, no, I don't think that lack of a 24 temperature is the end all to ruling out 25 bacteremia. But deciding whether bacteremia is 0126 1 the cause of an illness or disease state is, I 2 think, not concludable from these tests, these 3 tests anyway. 4 Q. In a hypothetical patient, Doctor, 5 if you have a low grade fever, one of two blood 6 cultures that are positive for Strep viridans, 7 elevated white blood cell count, elevated 8 C-reactive protein in a patient who has back 9 pain, would that cause you as a reasonable and 10 prudent physician to consider at the very least 11 diskitis or osteomyelitis as a potential cause? 12 A. I believe a potential cause as part 13 of the differential diagnosis would be 14 consistent with those blood tests. 15 Q. Do you know, and if you don't, tell 16 me, whether or not one treats suspected diskitis 17 or osteomyelitis of the spine in terms of 18 infection management with a low grade fever, one 19 of two blood cultures positive for Strep 20 viridans, elevated white blood count, elevated 21 C-reactive protein with the same course of 22 treatment as one would treat suspected 23 endocarditis? 24 A. No. I don't think the workup would 25 be -- there would be some overlap, I'm sure, but 0127 1 you would still be treating the primary 2 complaint of back pain with its requisite 3 differential diagnosis versus a workup of 4 endocarditis which would involve, I assume, 5 different symptoms and signs in its 6 differential. 7 Q. Would you defer to an infectious 8 disease specialist as it relates to the medical 9 management in terms of the appropriate 10 administration of antibiotics and the length of 11 antibiotic treatment if you have a patient with 12 low grade fever and with the symptoms that I've 13 just described before in terms of whether or not 14 you were considering endocarditis or diskitis in 15 terms of what the proper treatment would be? 16 A. If I had confirmed osteomyelitis or 17 endocarditis, I would consult infectious 18 disease. 19 Q. Or if you at least had within your 20 differential diskitis or osteomyelitis, you 21 would consult with infectious disease; correct? 22 MR. BULLOCH: Objection. 23 A. I don't think that I would say for 24 every time that I have an infectious etiology in 25 my differential diagnosis, which is just a list 0128 1 of plausible to a more or less degree 2 possibilities as to the final diagnosis, I don't 3 think I would consult infectious disease every 4 time it was in my differential diagnosis as it 5 is possible to rule those conditions out. 6 Q. Doctor, during the admission that 7 Dr. O'Hara managed, do you know whether there 8 was any consideration of an infection in the 9 spine? 10 A. I think the decision-making was 11 primarily made based on the results of the MRI 12 which showed -- I think we do have the results 13 of the MRI which showed the herniated disk 14 disease, and I don't think I see any sign of 15 infection or osteomyelitis which would have been 16 visualized. 17 Q. On the MRI? 18 A. On the MRI. 19 Q. Is a gallium scan more sensitive 20 than an MRI if one is considering infection as 21 being the cause of the patient's back pain? 22 A. I'm not a radiologist, but I believe 23 a gallium bone scan merely shows nonspecific 24 inflammatory changes whereas the MRI will show 25 specific anatomical changes. 0129 1 Q. So your answer is that the gallium 2 bone scan would not be more sensitive in terms 3 of helping one rule in or rule out infection as 4 compared to the use of an MRI? 5 MR. BULLOCH: Objection. 6 A. I don't think I can comment on which 7 one is more sensitive or specific. 8 Q. Fair enough. Let's fast forward to 9 your office visit on January 3, 2006. Having 10 walked through the two admissions from Geauga, 11 the next time you had any encounter with 12 Mr. Zerbian was January 3, 2006, and that was 13 because Dr. Goddard was not available to see 14 Mr. Zerbian; true? 15 MR. BULLOCH: Well, just to clarify 16 what he said at the previous deposition -- 17 MR. MISHKIND: John, I'm going to 18 stop you now because I'm not going to have you 19 clarify. I'm not going to have you testify. If 20 I'm stating things wrong, John, please do not 21 testify. Do not make speaking objections. I've 22 listened to enough of them. 23 Q. If I said something wrong, correct 24 me, Doctor, but I don't want Mr. Bulloch 25 testifying or clarifying or restating what was 0130 1 said before. Do you understand my question? 2 MR. BULLOCH: Do you understand his 3 question? 4 A. The question of what was the reason 5 I was seeing Larry Zerbian that day rather than 6 Dr. Goddard? 7 Q. Yes. 8 MR. BULLOCH: Objection. Go ahead. 9 A. I don't think I recall exactly the 10 reason why other than I often covered for his 11 patients when he was out of the office or 12 overbooked. 13 Q. In any event, when you saw him on 14 January 3, 2006, you wouldn't have had the 15 entire file that has been now provided to me 16 that's in a black -- what is this called? 17 MR. BULLOCH: Binder. 18 MR. MISHKIND: Is that a binder? I 19 guess it is. 20 Q. It says office records of Dr. Donald 21 Goddard. You wouldn't have had all the prior 22 labs, X-rays, progress notes. You would have 23 had just the information faxed over to you from 24 Dr. Goddard's office in Chesterland; true? 25 MR. BULLOCH: Objection. 0131 1 A. I don't -- other than the four 2 pieces of documentation that we have from the 3 3rd, I don't think I noted in the body what 4 records I had. But consistent with my 5 statements before, I would usually be given the 6 past medical history form and his most recent 7 list of medications and maybe the most recent 8 progress note. 9 Q. Now, the dictated progress note for 10 January 3, does this adequately take into 11 account what you've written and any findings 12 that you made during your examination? Does 13 this encapsulate the subjective, the objective, 14 and the assessment completely and accurately? 15 MR. BULLOCH: Objection. 16 A. My dictation from the visit on the 17 3rd is my summary of my subjective, objective, 18 and assessment and plan based on my recollection 19 at the time as well as my handwritten notes. 20 Q. I guess what I'm asking you, again 21 not to make it more difficult than necessary -- 22 MR. BULLOCH: Were you done, Doctor, 23 with your answer? 24 Q. Doctor, did I cut you off? 25 A. I think I'm done with that answer. 0132 1 MR. BULLOCH: Okay. 2 Q. I haven't cut you off in any of your 3 answers so far; have I? 4 MR. BULLOCH: That you recall. 5 Sorry. 6 Q. Doctor, before that comment was 7 made, have I cut you off at all? 8 A. No. 9 Q. The reason I'm asking this in 10 fairness to you is that your progress note is 11 rather detailed. It's got subjective, 12 objective, and assessment, and then you signed 13 it; correct? 14 A. Yes. 15 Q. It appears that you've sort of taken 16 into account that which you would have observed 17 as well as that which you had marked down in 18 your handwriting, and did you fairly encapsulate 19 and bring to a dictated form all of the relevant 20 findings on Mr. Zerbian on January 3, 2006? 21 MR. BULLOCH: Objection. 22 A. I will to the best of my knowledge 23 say yes. 24 Q. Where it says off and on fevers, and 25 we talked about this before, also chills and 0133 1 night sweats, were you able to determine how 2 long he had had the off and on fevers during 3 your encounter on January 3, 2006? 4 A. As far as not remembering this case 5 in my own memory but based on these, based on my 6 dictation, I don't think I quantify the time of 7 his fevers. 8 The night sweats I think were two 9 nights ago, and following that up with the next 10 sentence in the subjective of my dictation, I do 11 quantify him feeling like he had a cold over the 12 past week, so a week's worth of acute symptoms, 13 two nights ago night sweats. But, no, I don't 14 think I explicitly quantify the fever and 15 chills. 16 Q. Was the complaint of right tooth 17 pain, the subjective complaint of right tooth 18 pain to you on January 3, 2006, of any clinical 19 significance as it relates to his off and on 20 fever, chills, and night sweats? 21 A. Certainly, a dental infection could 22 give you fevers and chills and signs of 23 infection, and I think I defer to him seeing a 24 dentist in the note and I don't think considered 25 it much further. 0134 1 Q. Is it fair to say that in a patient 2 that is immunosuppressed that presents with 3 fevers, chills, night sweats, and complains of 4 tooth pain, at least within your differential 5 you have to have consideration for whether or 6 not that tooth pain is the potential situs for 7 bacteria causing symptoms of an infection? 8 A. Pain in and of itself would not 9 raise the specter of infection as much as 10 inflammation or purulent drainage or discharge, 11 and I don't think I even document examining his 12 mouth. 13 Q. That's my next question. 14 A. I'm sorry. No, I'm speaking ahead. 15 Q. That was the end of your answer? 16 A. The answer is done, yes. 17 Q. Thank you. My next question was, 18 there doesn't appear that you did any evaluation 19 as to whether or not there was any inflammation 20 or purulent drainage at the source of his tooth 21 pain; correct? 22 A. Not being a dentist, I did not, and 23 being assured that he was due to see his 24 dentist, I was deferring to his dental care for 25 that evaluation. 0135 1 Q. Did you know at the time of his 2 visit when he was due to see the dentist? 3 A. Let's see. I don't -- I don't 4 quantify that in my note. 5 Q. Did you have within your 6 differential the possibility, and again, I can 7 read your note so I know what your ultimate 8 assessment and plan was, but did you have within 9 your differential as you saw this patient the 10 possibility of infectious etiology as being the 11 cause of his fever, chills, and night sweats on 12 January 3, 2006? 13 A. I believe I was attributing his 14 fevers, chills, and night sweats to his most 15 recent viral upper respiratory infection and was 16 pursuing an evaluation for potential occult 17 bacterial infection as an explanation of his 18 elevated blood sugars or his uncontrolled 19 diabetes. 20 Q. You listened to his heart, and you 21 on examination found a regular rate and rhythm? 22 A. Yes. 23 Q. Would you have been using a 24 stethoscope to listen? 25 A. Yes. 0136 1 Q. Are you pretty good at your 2 auscultation? 3 A. Yes. 4 Q. You would expect that if you were 5 using the stethoscope properly in your 6 auscultation that you would be able to detect 7 any obvious heart murmur? 8 A. Yes. 9 Q. At least on January 3, 2006, you 10 didn't detect one; correct? 11 A. I did not. 12 Q. I think you told me previously, 13 Doctor, that you were not concerned about the 14 lab results from that admission, from that 15 encounter, office visit, you were not concerned 16 that those lab results were suggestive of an 17 infection; correct? 18 A. Correct. 19 Q. Now, as far as his antibiotic 20 regimen that he had been on previously, is it 21 fair to say that when you saw him on January 3, 22 2006, you were not aware that he had been a 23 patient at University Hospitals in Cleveland 24 after the September 4 or September 5 25 confinement? Is that a fair statement? 0137 1 A. At the time that I was seeing him on 2 the 3rd of January, I don't think I was aware of 3 that. 4 Q. Is it fair to say, also, that most 5 likely you were not aware of what visits 6 Mr. Zerbian had had with Dr. Goddard prior to 7 January 3, 2006, between the time of his 8 discharge from Geauga Hospital and when you saw 9 him on January 3, 2006? Is that a fair 10 statement as well? 11 A. Correct. 12 Q. All that information as to the 13 visits to Dr. Goddard and the visits to 14 University Hospitals of Cleveland would have 15 been outside of your knowledge base as of 16 January 3, 2006; is that a fair statement? 17 MR. BULLOCH: Objection. 18 A. I believe it was outside of the 19 documentation that I had with me during his 20 visit on January 3rd. 21 Q. Do you know if you had had the full 22 chart from Dr. Goddard for his visits to 23 University Hospitals of Cleveland and his office 24 visits to Dr. Goddard, do you know whether you 25 would have altered your assessment and plan for 0138 1 this patient as of January 3, 2006? 2 A. I do not know. 3 Q. Let me just take a look at my notes, 4 what I asked you from last time and what I've 5 asked you today, and I think we're probably very 6 close if not done. 7 A. Okay. 8 Q. There was a medical student that 9 apparently saw Mr. Zerbian in Dr. Goddard's 10 office on one of the office visits in October, I 11 believe. Without looking at the record, do you 12 know who some of the medical students were that 13 were rounding and/or working out of 14 Dr. Goddard's office? 15 A. Not in the Chesterland office. 16 Q. If you were to look at the office 17 record for October, would you have likely met 18 any of the medical students that were working in 19 the Chesterland office? 20 A. I rarely met his medical students. 21 I knew he had medical students that he was 22 precepting. 23 Q. I'll save that for Dr. Goddard. In 24 terms of your knowledge of Mr. Zerbian, from the 25 medical record for that visit as well as your 0139 1 involvement in the first admission and then your 2 giving the orders at the time of the second 3 admission, have you provided me with your best 4 recollection or recall based upon the records 5 concerning your findings and the significance of 6 your findings relative to Mr. Zerbian? 7 A. Yes. 8 Q. I asked you this at the previous 9 deposition, but I just want to make sure I'm 10 absolutely certain of this. 11 In terms of discussions with any 12 physicians, whether it be Dr. O'Hara, 13 Dr. Goddard, any of the emergency room doctors 14 that were involved at Geauga or any of the 15 physicians that were involved in the care of 16 Mr. Zerbian at University Hospitals in 17 Cleveland, have you had any discussion with 18 anyone as it relates to the cause of the 19 endocarditis, the onset of the endocarditis, and 20 his antibiotic treatment over the course of time 21 up to his diagnosis, anything with anyone along 22 those lines? 23 A. Not from any medical profession. 24 MR. MISHKIND: Very good. Doctor, 25 thank you very much. I hope that your first 0140 1 experience giving deposition testimony hasn't 2 been too painful. 3 THE WITNESS: No. 4 MR. BULLOCH: We will read the 5 deposition transcript. 6 - - - - - 7 (Deposition concluded at 11:06 a.m.) 8 (Signature not waived.) 9 - - - - - 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0141 1 AFFIDAVIT 2 I have read the foregoing transcript from 3 page 75 through 140 and note the following 4 corrections: 5 PAGE LINE REQUESTED CHANGE 6 7 8 9 10 11 12 13 14 15 16 17 _____________________ 18 MATTHEW B. PAWLICKI, M.D. 19 20 Subscribed and sworn to before me this _______ 21 day of _______, 2007. 22 23 _____________________ 24 Notary Public 25 My commission expires ______________. 0142 1 CERTIFICATE 2 3 State of Ohio, ) 4 ) SS: 5 County of Cuyahoga. ) 6 7 8 9 I, Cynthia A. Sullivan, a Notary Public within and for the State of Ohio, duly commissioned and 10 qualified, do hereby certify that the within named MATTHEW B. PAWLICKI, M.D. was by me first 11 duly sworn to testify to the truth, the whole truth and nothing but the truth in the cause 12 aforesaid; that the testimony as above set forth was by me reduced to stenotypy, afterwards 13 transcribed, and that the foregoing is a true and correct transcription of the testimony. 14 I do further certify that this deposition was 15 taken at the time and place specified and was completed without adjournment; that I am not a 16 relative or attorney for either party or otherwise interested in the event of this 17 action. I am not, nor is the court reporting firm with which I am affiliated, under a 18 contract as defined in Civil Rule 28(D). 19 IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal of office at Cleveland, 20 Ohio, on this 6th day of November 2007. 21 22 23 Cynthia A. Sullivan, Notary Public 24 Within and for the State of Ohio 25 My commission expires October 17, 2011.