COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO ---------------------------------------- : G. DELORES SAVAGE, et al., : : Plaintiffs, : : vs. : CASE NO. : 374280 COLUMBIA/HCA HEALTHCARE CORPORATION, : et al., : : Defendants. : : ---------------------------------------- DEPOSITION OF: BAHA SIBAI, M.D. TAKEN: By the Plaintiffs Pursuant to Agreement DATE: November 15, 2000 TIME: Commencing at 6:14 p.m. PLACE: University of Cincinnati Medical Sciences Building Room 4352 Cincinnati, Ohio BEFORE: Brenda J. Duncan, RMR, CRR Notary Public - State of Ohio 2 APPEARANCES: On behalf of the plaintiffs: Tobias J. Hirshman, Esq. of Linton & Hirshman Hoyt Block Suite 300 700 West St. Clair Avenue Cleveland, Ohio 44113-1230 On behalf of defendants Columbia/HCA Healthcare Corp. and hospitals and B.J. Burton, R.N.: Christopher S. Humphrey, Esq. and Mark D. Frasure, Esq. (via telephone) of Buckingham, Doolitle & Burroughs, LLP 4518 Fulton Drive, NW P.O. Box 35548 Canton, Ohio 44735-5548 On behalf of the defendants Sam Liu, M.D.; Michael Gyves, M.D.; Judy Nuza, C.N.M.; and Outreach Professional Service, Inc.: Chris Stackpole, Esq. of Reminger & Reminger 7 West Seventh Street Suite 1690 Cincinnati, Ohio 45202 - - - 3 I N D E X BAHA SIBAI, M.D. PAGE Cross-Examination by Mr. Hirshman 4 EXHIBITS MARKED REFERENCED Plaintiff's Exhibit 1-A 84 85 Plaintiff's Exhibit 1-B 84 85 (Exhibits retained by Mr. Hirshman.) - - - 4 1 BAHA SIBAI, M.D. 2 of lawful age, a witness herein, being first duly sworn as 3 hereinafter certified, was examined and deposed as follows: 4 CROSS-EXAMINATION 5 BY MR. HIRSHMAN: 6 Q. Good evening. 7 A. Hi. 8 Q. It's usually not evenings that we start these 9 things, but it is today. I'm Toby Hirshman. As I 10 indicated, I represent the plaintiffs in this medical 11 malpractice case where you've been retained as an expert 12 witness on behalf of the hospital, I believe; is that 13 correct? 14 A. Correct. 15 Q. Why don't you start by simply stating your full 16 name and address, home address? 17 A. Baha Sibai, S-i-b-a-i. My address is 621 East 18 Mehring Way, Cincinnati. 45202, I think. This is One Lytle 19 Place. 20 Q. How long have you been there? 21 A. Six months. 22 Q. You came from Tennessee, if I understand 23 correctly? 24 A. Correct. 5 1 Q. So up until six months ago, you were at the 2 University of Tennessee? 3 A. Yes. In Memphis. 4 Q. Tell me, if you would, why you changed 5 locations? 6 A. It's a better job. It's a promotion. 7 Q. What was your title before and what has it been 8 promoted to now? 9 A. Before, I was the chief of the division of 10 maternal fetal medicine, department of obstetrics and 11 gynecology. And now I'm the chairman of the department of 12 obstetrics and gynecology. 13 Q. So the scope of your oversight is not only 14 maternal fetal medicine now, it's obstetrics and gynecology? 15 A. Everything. 16 Q. Everything to do with obstetrics and 17 gynecology? 18 A. See, again, obstetrics and gynecology, the 19 chairman above maternal fetal medicine, productive 20 endogynecology, GYN oncology, and general obstetrics and 21 gynecology. 22 Q. So rather than just being involved with 23 maternal fetal medicine now, you're involved with the entire 24 breadth and scope of obstetrics and gynecology, at least in 6 1 an oversight position? 2 A. Oversight, correct. 3 Q. Clarence McLean is a colleague of yours here? 4 A. He is a member of the faculty, yes. 5 Q. And I presume that makes him a colleague of 6 yours? 7 A. If you say so, okay. 8 Q. Do you wish to dispute that he's a colleague of 9 yours in some fashion? 10 A. No. 11 Q. So is James Liu, if I'm not mistaken? 12 A. Yes. He's faculty in my department. 13 Q. There's a defendant in this case by the name of 14 Liu. 15 A. Yes. 16 Q. Sam Liu. 17 A. Yes. 18 Q. Do you know what the relationship is between 19 those two? 20 A. I have no idea. 21 Q. If any? 22 A. I don't know. I would be surprised if they 23 were related, because Liu, I think, is a common Asian name. 24 Q. I have briefly looked at some of the materials 7 1 that you've reviewed here. I've got a letter of yours which 2 articulates a list of some materials. We don't have to 3 restate that. 4 But what I'd like to know is whether or not you 5 have reviewed any materials in addition to the materials 6 that are stated in paragraph 1 of your letter of August 7 11th, 2000. 8 A. Yes. I received additional depositions. 9 Q. Tell me, if you would -- in other words, you 10 received additional depositions after you wrote your August 11 11th, 2000 report? 12 A. I think so, yes. 13 Q. Tell me, if you would, what additional 14 depositions you reviewed after that report was written? 15 A. I received the deposition of Deborah Amerson, 16 B.J. Burton. 17 Q. You already had Burton's before? 18 A. Oh, sorry. Desiree Marsh. I think this is it 19 for depositions. Then I received reports from experts in 20 this case. 21 Q. And what reports are those? 22 A. I have one by Dr. Ashmead. 23 Q. Do you know Dr. Ashmead, by the way? 24 A. Yes. 8 1 Q. You're familiar with him as a colleague in the 2 same area of practice? 3 A. Yeah. He's in maternal fetal medicine. 4 Q. So you've met him at seminars and at various 5 functions in the past? 6 A. I will say I probably have seen him at some 7 meetings. 8 Q. You've already reviewed the report of 9 Dr. Howard Tucker, I believe? 10 A. Yes. 11 Q. Any other reports? 12 A. Here's another report by -- 13 Q. Dr. Gatewood? 14 A. Gatewood, yes. 15 Q. Any others? 16 A. No. This is it. 17 MR. FRASURE: Doctor, you have Dr. Davis 18 there? Did you mention him? 19 MR. HIRSHMAN: No, he didn't mention him. 20 THE WITNESS: Dr. Who? 21 MR. FRASURE: S. Edward Davis, maternal fetal 22 medicine, of Hackensack, New Jersey? 23 THE WITNESS: No, I didn't. 24 BY MR. HIRSHMAN: 9 1 Q. Do you recall reviewing a report from 2 Dr. S. Edward Davis? 3 A. This name is familiar, but I can't find his 4 report here. 5 Q. All right. Would his name be familiar from 6 circumstances outside the scope of this litigation perhaps? 7 A. No. It could be lost somewhere in my office. 8 Q. Okay. Any other reports? 9 A. No. This is it. 10 Q. You've written a report dated August 11th, 11 2000, which you addressed to Mark Frasure. 12 MR. HIRSHMAN: I almost elevated you to doctor 13 status. 14 MR. FRASURE: Mark, thank you. I can get sued 15 now. 16 THE WITNESS: Join the club. 17 BY MR. HIRSHMAN: 18 Q. Is this the only report you wrote? 19 A. Yes. 20 Q. Have you testified as an expert witness in 21 civil litigation in the past? 22 A. Yes. 23 Q. Can you give me some idea as to how often you 24 are involved in -- let's do this in some sort of a way that 10 1 makes sense to you. 2 A. I have an answer. I can give it immediately. 3 Q. Do that. 4 A. Since 1981, I have reviewed about 140 records, 5 I have given about 40 to 50 depositions, and I appeared in 6 court about 15 times. 7 Q. How many of those were for plaintiff, how many 8 for defendant? 9 A. I will say it has been running somewhere about 10 two-thirds defendant, one-third plaintiff for reviews. 11 Depositions is less, and court is less. 12 Q. Depositions and court are less on which side? 13 A. On the plaintiff side. 14 Q. So as it relates -- the two-thirds -- one-third 15 is testimony in court, that split that you just gave us? 16 A. No, no. The review is what is one-third. I 17 will say probably about 50/50 for deposition and 20/80 for 18 court. 19 Q. 20 percent for whom? 20 A. Plaintiff. 21 Q. Have you ever worked for the firm of Reminger & 22 Reminger before? 23 MR. STACKPOLE: I don't believe he's working -- 24 MR. HIRSHMAN: He isn't right now. I'm asking 11 1 whether he ever did before. 2 MR. STACKPOLE: I apologize. 3 A. The name is familiar. I could have worked for 4 them once before. 5 BY MR. HIRSHMAN: 6 Q. How about Buckingham, Doolittle? 7 A. No. This is the first time. 8 Q. Have you been involved in reviewing or 9 testifying, either by deposition or at trial, in cases 10 dealing with HELLP syndrome? 11 A. Oh, I'm sure I did. 12 Q. What percentage of your cases would you say 13 that you've reviewed have dealt with that syndrome? 14 A. Oh, I cannot give you a number. 15 Q. A significant number, though? More than ten? 16 A. I will say yes. 17 Q. Okay. Can you remember any of the attorneys 18 involved in those HELLP syndrome cases? 19 A. I'm trying to remember. I'm bad at names. 20 There is a case in Vermont. I can't remember the name of 21 the attorney. Once it comes to my mind, I will give it -- 22 and then I'll give it back to you. If I remember or find 23 out, I'll give you this. 24 THE WITNESS: I'll give this to you and you can 12 1 give it to him. 2 BY MR. HIRSHMAN: 3 Q. There's some questions I don't mind asking. 4 Some questions, I wish I didn't have to ask them, but I have 5 to ask them anyway, because I have to represent my client. 6 A. That's fine. 7 Q. One of the questions I don't like to ask, but 8 I'm going to ask you is, have you ever been sued? 9 A. Yes. 10 Q. On how many occasions? I'm talking about suits 11 for medical malpractice. I don't care if you have a 12 contract dispute or any other type of litigation. 13 MR. HUMPHREY: Can I have a continuing 14 objection to this line of questioning? 15 THE WITNESS: That's okay. 16 MR. HUMPHREY: Go ahead. 17 A. I would say probably I have been named five or 18 six times. 19 BY MR. HIRSHMAN: 20 Q. Those are all in Tennessee? 21 A. Yes. 22 Q. Any of them deal with HELLP syndrome? 23 A. No. 24 Q. I know one of them was the Meserv case versus 13 1 UTMG. Are you including that one? 2 A. Actually, this I wasn't sued. 3 Q. You weren't a party? 4 A. I wasn't a party. Actually, all the cases, 5 they ultimately got dropped. I got named, being the chief 6 of the division of maternal fetal medicine. So I have never 7 had a case set out or a case went to court against me. 8 I have never given a deposition in any case to 9 date, other than being a fact witness as a division chief, 10 if you want to put it. 11 Q. In the Meserv case, you gave a deposition? 12 A. As division chief. 13 Q. Okay. In fact, you looked at some fetal 14 monitoring strips, if I'm not mistaken, in that case? 15 A. As the division chief, I got asked often to do 16 this. 17 Q. I believe, if I'm not mistaken, that case 18 involved a nurse midwife? 19 A. Yes. 20 Q. And a nurse midwife's involvement in the care 21 and treatment of a patient who was being monitored on a 22 fetal monitoring strip? 23 A. Correct. 24 Q. And that fetal monitoring strip was alleged to 14 1 have been misinterpreted, correct? 2 A. Yes. 3 Q. And you read that strip and rendered the 4 opinion in that case that the strip was properly interpreted 5 as showing no evidence of the need for immediate delivery? 6 A. I will say yes. It was variable deceleration, 7 if I recall. 8 Q. So your conclusion in that case, from reading 9 the fetal monitoring strip, was that there were no findings 10 on that strip that suggested that it was a nonreassuring 11 strip? 12 MR. HUMPHREY: Don't guess, Doctor. If you 13 can't remember specifically what you saw on that 14 strip at that time, I don't want you to guess. You 15 can tell him that. 16 BY MR. HIRSHMAN: 17 Q. You can tell me that if it's true. But that's 18 not an invitation to cancel your memory. I'm sure you 19 wouldn't do that. 20 A. Of course, I wouldn't do that. 21 The way I interpreted that was variable 22 decelerations that you can see during the pushing, if I 23 recall. 24 Q. You had a subsequent opportunity to read that 15 1 same strip in another case? 2 A. I don't remember if this is the same case or 3 not. 4 Q. Okay. What was the end result of that 5 particular case, the Meserv case? 6 A. There was a verdict for the plaintiff against 7 the corporation who employed the nurse midwife. 8 Q. Which was the same corporation that employed 9 you, was it not? 10 A. Yes. 11 Q. And that verdict was how many million? 12 MR. HUMPHREY: Well, I'm going to object to 13 this other litigation. I don't think it's relevant. 14 But you can go ahead and answer. 15 A. I really don't know. As of now, I have no 16 idea. 17 BY MR. HIRSHMAN: 18 Q. Now, that's part of the deposition I don't 19 enjoy doing, so we'll move on. 20 A. That's okay. 21 Q. Let's get into some issues regarding what your 22 practice was in Tennessee and what kind of a practice you 23 have here. Are they similar in terms of the nature of the 24 patients that you see? 16 1 A. I think they're almost the same. There it was 2 a tertiary care facility. It's that way here. I would 3 think Memphis was more of a referral facility than this is. 4 Q. This is a two-state area? 5 A. Which one? 6 Q. Here. I mean, do you get -- you get referrals 7 here from Kentucky, undoubtedly. You get referrals here as 8 well from Ohio? 9 A. I think the difference is that you have too 10 many medical centers here within what they call the hundred 11 mile radius. This is why you don't have this what they call 12 big referral area. 13 In Tennessee, we served five, six states, 14 actually. We didn't have any competition. We used to get 15 patients referred about 250 miles a way, which you have so 16 many medical centers there. 17 You have Lexington, Dover, hundred miles, Ohio 18 State, which is 80 miles. So you don't have this big 19 referral area. 20 Q. So in Tennessee you would get patients, 21 including preeclamptic patients, referred to you from 22 hundreds of miles away? 23 A. Yes. 24 Q. And in Tennessee, you would get patients with 17 1 HELLP syndrome referred to you from hundreds of miles away? 2 A. Yes. 3 Q. And that was not uncommon, which probably 4 explains why you've seen so many HELLP syndrome cases? 5 A. I have probably seen more HELLP syndrome than 6 anybody alive I know in the world. 7 Q. And you attribute that to the broad geographic 8 area that you were getting referrals from? 9 MR. HUMPHREY: If you know. 10 A. I would say we had a very large tertiary care 11 facility because we served 80 counties in the mid-south 12 area. 13 Q. How many HELLP syndrome cases would you say 14 that you've had the opportunity -- we're going to talk -- 15 we're going to use a term here that we're going to define -- 16 that you've had an opportunity to be involved with. My 17 guess is, given your administrative position, we need to 18 define what it is to be involved. 19 And I'm going to ask you to do that for me. As 20 you tell me how many patients you've been involved in 21 treating with HELLP syndrome, I'll need some sort of 22 definition from you as to what that involvement is. 23 A. I would say I have been involved in every 24 patient who had HELLP syndrome in Memphis. 18 1 Q. In Memphis? 2 A. Yes. 3 Q. How many facilities did you work at there? 4 E.F. Crump was one of them? 5 A. This is our regional facility. 6 Q. Crump? 7 A. Yes. 8 Q. Then there's Baptist? 9 A. I will say Baptist was a small part. You know, 10 I didn't do much at Baptist. I consulted a few patients. 11 We covered the Methodist Hospital there in the most recent 12 years before I left. 13 So I will say the majority of them were at one 14 hospital, which is the regional medical center. 15 Q. Which is Crump? 16 A. Which is Crump. 17 Q. That's E.F. Crump? 18 A. E.H. Crump. 19 Q. E.H. Crump. Okay. 20 So how many HELLP -- how many years were you 21 there? 22 A. 22. 23 Q. How many HELLP syndrome cases do you think you 24 had the opportunity to be involved in caring for during that 19 1 22-year period? 2 A. I will say somewhere about 600 to 700. 3 Q. And when we say "caring for," what are we 4 really talking about? What was your involvement? 5 A. I became aware of them or I was directly 6 involved in their management or I reviewed their medical 7 records. 8 Q. So some of them you actually were the attending 9 on? 10 A. Yes. 11 Q. Some of them you were involved in -- on some 12 sort of a consultation basis? 13 A. Yes. 14 Q. Some of them you were probably involved in as 15 an overseer of residents who were working? 16 A. Yes. 17 Q. And some of them you were involved in as a 18 person doing research and attempting to discern patterns 19 from the cases that had gone through that facility? 20 A. Yes. 21 Q. Any other capacities in which you were involved 22 in those cases? 23 A. Well, I'm sure I got called about HELLP 24 syndrome from all over the world, actually, about patients, 20 1 management. 2 Q. So when you talk about 600 to 700, you're 3 talking about patients that actually were in Memphis for 4 their treatment? 5 A. Yes. 6 Q. You're not talking about the case that somebody 7 called you about from California or -- 8 A. No, no. 9 Q. -- or Ireland or someplace? 10 A. Correct. 11 Q. So let's talk about preeclampsia cases. Would 12 the number be larger? 13 A. I will say probably about 15,000. 14 Q. How many cases of severe preeclampsia? 15 MR. HUMPHREY: What are you using to go from 16 preeclampsia to severe preeclampsia? What's your 17 definition to do that? 18 A. I was going to tell him that every woman who 19 has HELLP syndrome is severe by the -- 20 BY MR. HIRSHMAN: 21 Q. But you can have severe preeclampsia without 22 HELLP syndrome? 23 A. Yes. 24 Q. If we're talking a number of indicia, one being 21 1 hypertension, another being protein in one's urine -- 2 A. Let me make the definition. 3 Q. Great. You're the expert. 4 A. A woman could have severe preeclampsia if she 5 had severe hypertension plus any proteinuria or if she had 6 mild hypertension plus severe proteinuria or if she had 7 hypertension with proteinuria and she had 8 thrombocytopenia -- I can give you at least 15 definitions 9 which makes it almost severe preeclampsia. 10 Q. This much you've reviewed -- 11 A. She had severe preeclampsia. We are not going 12 to argue about this. 13 Q. When Wanda Wright stepped foot into St. Luke's 14 Hospital, she had severe preeclampsia? 15 A. Yes. 16 Q. And it was discernible very shortly thereafter? 17 A. Yeah. I will say, you need to have at least an 18 hour period to see what the blood pressure and how it is. 19 If you have four-plus proteinuria, somebody would make a 20 diagnosis of severe preeclampsia. 21 Q. So, certainly, if she got to the hospital 22 before 1:00 -- correct? 23 A. Close to or -- about six minutes before 1:00. 24 Q. By 2:00? 22 1 A. Yeah. 2 Q. -- that was well known? 3 A. Yes. 4 Q. Let's talk about HELLP syndrome plus hematoma 5 of the liver. And I use hematoma of the liver -- I state it 6 that way in order to include both subcapsular and 7 intraparenchymal hematomas. 8 MR. FRASURE: What was the last word? 9 A. Intraparenchyma. 10 BY MR. HIRSHMAN: 11 Q. Is it fair to discuss liver hematomas in that 12 sort of a global sense? 13 A. Definitely. There's no doubt. 14 Q. How many cases of HELLP syndrome plus liver 15 hematoma have you seen in those same 22 years? 16 A. It's very difficult to estimate, because if you 17 don't due imaging, it's impossible to know. What we usually 18 do -- imaging we do on selected cases. So it's very 19 difficult to give you a total figure. 20 I can tell you how many women who had 21 subcapsular liver hematoma that are leaking or ruptured. I 22 will say probably I have seen about ten of those. 23 See, intraparenchymal hematoma becomes a very a 24 difficult frequency to assess. If you don't do a routine 23 1 imaging, it's very difficult to estimate. 2 Q. So you would say that you have HELLP syndrome 3 plus a leaking or ruptured subcapsular hematoma? 4 A. About ten women. 5 Q. Ten women. And you have seen -- are you 6 suggesting that you've never seen an hepatic hematoma HELLP 7 syndrome patient who was not leaking or ruptured? 8 MR. HUMPHREY: Objection. I don't think he 9 said that. 10 A. I don't understand your question, I guess, to 11 be honest with you. 12 BY MR. HIRSHMAN: 13 Q. You've indicated that you've seen, you believe, 14 ten cases of HELLP syndrome with a leaking or ruptured 15 subcapsular hematoma? 16 A. Yes. 17 Q. I presume you've also seen patients who have a 18 subcapsular or intraparenchymal hematoma that is not leaking 19 or ruptured? 20 A. When you talk about subcapsular hematoma, most 21 of them are leaking anyhow. 22 There's a difference between leaking and being 23 a frank eruption that goes through the parenchyma. 24 So, yes, I have seen several other people who 24 1 had what you call intraparenchymal hematoma. That has 2 nothing to do with subcapsular. They're completely 3 different. 4 One of them has to do with a potential space 5 and the other one is in the substance of the liver. 6 Q. Are you able to tell us in this case, Wanda 7 Wright, whether she had an intraparenchymal hematoma of the 8 liver? 9 A. By definition, she started with parenchyma, and 10 then she has to go into a subcapsular. What she had is a 11 ruptured subcapsular liver hematoma. 12 Q. What you're saying is that, by definition, all 13 liver hematomas are intraparenchymal bleeds? 14 A. It starts as something, as bleeds. This is how 15 a subcapsular liver hematoma develops. 16 See, remember, the capsule of the liver is 17 very, very tightly adhered into the liver parenchyma. So 18 there is really no space. The only way you can develop 19 subcapsular liver hematoma is to start bleeding in the liver 20 and has to dissect. 21 Q. So the difference between the two, when you 22 talk about subcapsular hematoma, you're discussing where it 23 is that the blood collects within the liver? You're 24 describing the place where the blood rests between the 25 1 parenchyma and the capsule itself? 2 A. Correct. 3 Q. And if you're talking about an intraparenchymal 4 hematoma, as that term is usually used, it's a description 5 of a collection of blood someplace other than right under 6 the capsule? 7 A. Correct. And they're completely different. 8 Q. And in this case, it's your testimony that 9 Wanda Wright had a subcapsular hematoma? 10 A. No doubt about it. 11 Q. Can you tell me whether she also had an 12 intraparenchymal hematoma? I use that term as opposed to an 13 intraparenchymal bleed. In other words, did she have a 14 collection of blood intraparenchymally? 15 A. Later, everybody, after you do surgery of them, 16 will have. We don't know in her case whether she had it 17 before. 18 Q. Okay. 19 A. There is one thing we are sure about, that she 20 had subcapsular liver hematoma. The intraparenchymal 21 hematoma does not lead to maternity death, because it's 22 really localized in one area. 23 Q. And it never gets to the surface and never get 24 into a position where it can leak into the peritoneum? 26 1 A. Correct. All it produces, really, is changes 2 inside the liver parenchyma and produces elevated liver 3 enzymes, but does not produce massive blood loss, because 4 it's a localized area in the liver. 5 Q. Okay. So are you telling me that there are 6 only ten cases of hepatic hemorrhage that you know that you 7 treated or were involved with? 8 A. I will say yes. 9 Q. Okay. 10 A. Considering the subcapsular liver hematoma. 11 Q. And you know that because you imaged them and 12 proved them radiographically? 13 A. Or we found them at time of surgery or because 14 of complaints. 15 Q. I think you indicated that there are certain 16 indications for doing a -- an imaging study of the liver. I 17 think you began to say that, and we kind of skimmed over it. 18 A. Yes. 19 Q. Tell me what those indications are for doing an 20 imaging study of the liver. 21 MR. HUMPHREY: With a patient who they suspect 22 has HELLP syndrome, Toby? 23 BY MR. HIRSHMAN: 24 Q. Well, let's -- that's, I suppose, what you're 27 1 going to tell me. Let's put it this way. What are the 2 indications for doing a -- an ultrasound, a CT scan, or an 3 MRI of the liver in a woman who presents with HELLP 4 syndrome? 5 A. Actually, we try to do this correlation based 6 on a study I did with Dr. John Barton, who is in Lexington. 7 He was a fellow with me. 8 And at some times we were doing them, trying to 9 understand the findings in the liver; and in certain 10 patients, we were doing them because there were some 11 suggestions. 12 So, to answer your question, we actually went 13 back and we tried to do what you call a correlation. 14 But when I teach -- I think this is the best 15 way to put it -- I say that, you know, when should you do a 16 CT scan of the liver? Any patient who has -- see, either 17 scan or ultrasound. 18 Q. Pardon me? 19 A. Scan or ultrasound. 20 Q. I think you said that. 21 A. Yeah. I said only CT scan. If you have a 22 woman who has HELLP syndrome -- this is the key point. You 23 should have HELLP syndrome to begin with, and she develops 24 what we call relapsing hypotension. 28 1 Q. Which is what? 2 MR. FRASURE: Hypo or hyper? 3 THE WITNESS: Hypo. 4 BY MR. HIRSHMAN: 5 Q. Which means what, hypotension that comes and 6 goes? 7 A. Yes. What happens, again, if you have somebody 8 who starts with high blood pressure, slightly elevated blood 9 pressure, and then suddenly they become hypotensive, you 10 give them fluid and blood, they go back, blood pressure go 11 up. Later on, they go down. This suggests that they are 12 bleeding. 13 Q. Okay. 14 A. One thing to think of, they are bleeding, most 15 likely, from the liver. Another one, if you have a patient 16 who has severe massive ascites, if you have a patient who 17 has severe shoulder or neck pain. 18 Q. Shoulder or neck pain? 19 A. Yeah. 20 Q. How about -- go ahead. Give me your list. 21 A. If you have severe thrombocytopenia, like a 22 platelet count less than 20,000. I will say, in essence, 23 this is what I teach people as some of the things. 24 If you are faced with a woman who has HELLP 29 1 syndrome that radiological syndrome might be indicated. 2 Q. How about epigastric pain? 3 A. That's seen in more than two-thirds of woman 4 with HELLP syndrome, so the answer is no. 5 Q. Would you agree with me that CT scanning of 6 such women is a clinical tool rather than simply a research 7 tool? 8 A. At what level? I'm not clear, you know. 9 Q. It's -- you would agree with me that using CT 10 scanning to screen women who present in the fashion that you 11 just described is not simply something that is done in order 12 to do a clinical trial, but rather is something that you do 13 in order to provide appropriate clinical care? 14 A. I will say it gives you information that might 15 help you in deciding whether you need to do surgery and use 16 what we call conservative management, if this is your 17 question. 18 Q. So it's helpful in making choices for the 19 patients who are treated and diagnosed in that fashion? 20 A. If they are stable. And if the patient is 21 unstable, then the CT scan becomes irrelevant. 22 So, really, the bottom line is that the CT scan 23 can be used to follow these patients, if you are not 24 planning to operate on them, if this is your question, and 30 1 they are stable. 2 Q. And by "stable," you mean they have -- 3 A. Hemodynamically. 4 Q. Hemodynamically stable? 5 A. Yes. This is the word. 6 Q. Now, the ten cases that you're aware of where 7 you've seen women with HELLP syndrome and a hepatic 8 hematoma, can you tell me how many of them survived? 9 A. Those who ruptured or just hematoma leaking or 10 whatever? 11 Q. Of these ten, I take it some of them ruptured 12 and some of them didn't? 13 A. Yes. 14 Q. Of those -- let's talk about the ten as a 15 group, and then we'll break them out afterwards. 16 Of the ten women that you're aware of who 17 were -- who you saw and treated with hepatic hematoma, how 18 many of them survived? 19 A. The ones that ruptured or unruptured? 20 Q. Let's deal with the full universe of them and 21 then we'll deal with the subuniverses of them afterwards. 22 Let's take all women with hepatic hematoma. 23 A. Let me think. 24 Q. And HELLP syndrome, obviously. 31 1 A. I'm confused now. Do you want mortality in 2 HELLP syndrome or HELLP with subcapsular liver? 3 Q. We're talking about the ten women with HELLP 4 syndrome and hepatic hematoma that you've seen. How many of 5 them survived? 6 A. I think all probably -- I had -- probably three 7 women died. 8 Q. Three out of ten? 9 A. Yes. 10 Q. Now, of those that -- of that same ten, how 11 many of them suffered long-term morbidity? 12 A. What do you mean by long-term morbidity? 13 Q. How many of them suffered a -- an adverse event 14 that created a permanent medical disability thereafter? 15 A. It's very difficult to answer this question. 16 I'm trying to see how to put it in a better way. 17 All these women will have morbidity for certain 18 time period, because you're going to have acute renal 19 failure, pulmonary edema, ARDS. Almost all these women will 20 have morbidity. You are saying if they survive this 21 morbidity -- is this your question -- how many of those 22 would have problems later on? 23 Q. Correct. We can agree that Wanda Wright 24 suffered long-term morbidity? 32 1 A. Well, she died. 2 Q. She ultimately died? 3 A. Yeah. 4 Q. And she died as a result of the events that 5 occurred on March 17th? 6 A. I will say yes. 7 Q. Of the year 1998? 8 A. Yes. 9 Q. Are you able to give me this figure, or are you 10 uncomfortable with some of the terminology I'm using here? 11 A. It's very difficult to give, you know, because 12 some of these women had renal failure and required dialysis. 13 I had to wait a long time for their renal 14 function to come back and so on. Some of them, you know, 15 ended up on ventilator and had problems related to ARDS and 16 so on. 17 This is why it's very difficult to give you, 18 because all of these complications happen because of that. 19 Q. Let's put it this way. How many of them did 20 not walk out of the hospital ultimately on their own two 21 feet of the ten that we've been discussing? 22 A. Well, we know three died. 23 Q. Of the other seven, how many of them did not 24 walk out of hospital ultimately on their own? 33 1 MR. FRASURE: You mean walk as opposed to being 2 put in a bed? I don't understand. 3 A. Patients don't walk from the hospital. All of 4 them -- they are transferred in a wheelchair. They wouldn't 5 let them walk. 6 MR. HUMPHREY: Toby, is what you're asking how 7 many of these ten patients had -- 8 A. Brain damage? 9 MR. HUMPHREY: -- long-term morbidity 10 associated with the liver hematoma? Is that what 11 you're asking? 12 BY MR. HIRSHMAN: 13 Q. That was the term I used first of all. You 14 weren't happy with that term. We moved off of that. That's 15 the question exactly. How many of those seven who did not 16 die suffer long-term morbidity? 17 A. See what I'm saying? Long-term morbidity could 18 be they had problem with their kidney. This is why -- if 19 you are talking about their brain, those who have the brain 20 ultimately will die. 21 Q. Let's ask that question, then. How many of 22 those seven suffered neurologic deficits? Let's make it 23 easy, brain damage. 24 A. I would say none, if they didn't die. 34 1 Q. Let's now talk about the four, I think that you 2 indicated had ruptured hematomas of the liver. Is that the 3 number that you mentioned, four? 4 A. I forgot. Did I say four? Probably four or 5 five. You didn't ask me, but probably -- 6 Q. I thought we mentioned it. 7 A. Probably you remember from reading the article, 8 I think, about the four. 9 Q. I don't know what article you're talking 10 about. Is there an article that you wrote on this subject? 11 A. I wrote about HELLP syndrome in articles. 12 Q. Okay. So how many do you think sustained a 13 rupture of the liver of those ten? 14 A. Probably half of them. And I think that three 15 of those patients are the ones who died. 16 The most recent was, I will say, about a year, 17 year and a half ago. 18 Q. Before the one a year, a year and a half ago, 19 when was the next patient in terms of proximity to the 20 present? 21 A. We had one, I will say, about -- probably about 22 six or seven years ago. And we had one before that. I 23 don't know when. 24 Q. Those are the deaths that you're talking about 35 1 now? 2 A. Yeah. 3 Q. Suffice it to say, based on what we've just 4 been discussing, not all patients with HELLP syndrome and 5 hepatic hematoma are predestined to either death or severe 6 devastating neurologic injury. Fair statement? 7 A. Correct. 8 Q. And there are mechanisms that can be utilized 9 in order to diagnose the condition if the patient presents 10 in a fashion that suggests that the condition may exist? 11 MR. HUMPHREY: When you say "condition," are 12 you talking subcapsular hematoma? 13 MR. HIRSHMAN: Correct. 14 A. Yes. 15 BY MR. HIRSHMAN: 16 Q. And there are treatments that can be rendered 17 to enhance the chances of healthy survival in those women 18 who are promptly diagnosed with the condition? 19 MR. HUMPHREY: Objection. You can answer. 20 A. I don't know what you mean by the word 21 "treatments." You know, the only thing you can do is 22 supportive care. There is nothing I'm aware of that you can 23 call treatment. There is no treatment for this condition. 24 BY MR. HIRSHMAN: 36 1 Q. Well, this much we know, if a patient has a 2 subcapsular hematoma, one can do a CT scan. And if it looks 3 like the condition is progressing, you can perform yet 4 another one to see whether there has been a progression of 5 the condition, can you not? 6 A. Correct, yeah. But it's not treatment. 7 Q. If you see progression of the condition, you 8 are then in a position to perform surgery before the rupture 9 occurs? 10 A. No. That is not -- you don't perform 11 surgery. 12 Q. Not even if you see a progression and an 13 advancement of the hematoma? 14 A. As long as they're hemodynamically stable, you 15 don't need to. Again, this is survival -- the best survival 16 is not to do anything. That's what we tell everybody. 17 Once they rupture and they start having 18 intervention, this is when the mortality. So, really, your 19 management for this patient is to follow how they are and, 20 most important, to see hemodynamically how they're 21 progressing and be prepared if they rupture. 22 Q. To take swift action? 23 A. To deal with it and see what will happen. 24 When I give this lecture, I tell the people, 37 1 what you need to do, have blood and pray. I still teach 2 everybody, you need to do a lot of praying, because I'm not 3 aware that there is anybody in the world who can do anything 4 once they rupture, other than to do what we call palliative 5 procedures, which was done in this case. 6 Q. Once the rupture occurs -- 7 A. Yes. 8 Q. -- you need to be in a position to promptly 9 give blood and blood products, correct? 10 A. Correct. 11 Q. You need to be in a position to promptly give 12 fluids, correct? 13 A. Yes. 14 Q. All of that is done in order to support the 15 patient hemodynamically? 16 A. Correct. 17 Q. And to deal with whatever coagulopathy might 18 exist, correct? 19 A. Correct. 20 Q. By prompt administration of those products, you 21 mean having that stuff right there next to the patient's bed 22 ready to be administered, correct? 23 A. Yes. 24 Q. That wasn't done here, was it? 38 1 A. What do you mean "it wasn't done"? I'm not 2 clear. 3 Q. That was not done with Wanda Wright, was it? 4 A. You mean having the blood available? 5 Q. Correct. 6 A. They didn't know she had the hematoma. 7 Q. No, they didn't. You're correct. 8 A. Right. 9 Q. Well, they didn't have the blood available 10 then? 11 A. The blood is in blood bank. 12 Q. The blood had not been cross-matched? 13 A. It takes 10 to 15 minutes. Some of these women 14 might require 300 units of blood. This is why we might say, 15 you might need to have all the blood in this state, not only 16 in your hospital. This is the whole idea. 17 When I was called at Denver, it was ultimately 18 900 units of blood, blood products, when they called me. 19 Q. In this case, they didn't have any blood 20 available, did they, immediately? 21 A. Well, it was in the blood bank. 22 Q. It wasn't at her bedside? 23 A. No. We're not talking about -- when we talk 24 "have blood," it's not next to her bed. The blood available 39 1 in the hospital. 2 Q. How long did it take them from the time of the 3 rupture to administer their first unit of blood product in 4 this case? Do you know? 5 A. I don't know the exact time. I know she 6 received a lot of fluids. She received multiple units of 7 blood and she received platelets. So, really, they had the 8 blood and blood products in the hospital. This is really 9 the most important thing, is that to make sure you have this 10 in the hospital. 11 Q. Now, you would have, if this was a patient of 12 yours, had that blood administered within half an hour, 13 wouldn't you have? 14 A. I will say an hour. It will take me an hour to 15 get blood. 16 Q. Who are you insured by? 17 MR. HUMPHREY: Objection, you can answer. 18 A. Here? 19 BY MR. HIRSHMAN: 20 Q. Correct. 21 A. I don't know yet. We used to be with one 22 company. We're shifting. I don't know yet. 23 Q. Who were you with up until -- at the present 24 time, you've got insurance, I presume. You've got coverage? 40 1 A. We shifted with a trust fund here that's by the 2 University. 3 Q. And you don't know how -- you have a trust fund 4 that provides you with your complete coverage, or do you 5 have some coverage that's provided by an insurance company 6 as well? 7 A. No, no. It's on the trust fund. Everyone's 8 trust fund now. It started in July or August. 9 Q. What, if any, association or relationship did 10 you have with Columbia/HCA? 11 A. I have no idea. All I know is that Columbia is 12 a hospital. 13 Q. Did you work at Columbia hospitals? 14 A. No. 15 Q. Did you have any sort of a financial or other 16 relationship -- financial, academic, professional 17 relationship with Columbia/HCA? 18 A. No. We never even have in Memphis Columbia 19 hospital, so -- 20 Q. Okay. Am I correct in understanding that Wanda 21 Wright never developed eclampsia? 22 A. True. 23 Q. And that she never developed seizures? 24 A. She had seizures later on. 41 1 Q. As a result of the neurologic injury she had -- 2 A. Yeah. 3 Q. But she didn't have seizures brought on by an 4 eclamptic condition? 5 A. No. She didn't have eclampsia, so if she 6 didn't have eclampsia, she didn't have seizure. 7 Q. When was it that it became readily apparent 8 that Mrs. Wright had HELLP syndrome, from your review of the 9 record? 10 A. Once they got the blood tests. 11 Q. Do you know what time that was? 12 A. I think the blood reached the lab somewhere 13 about 1:45. The results were called about 2:50. So by 3:00 14 the blood tests suggested the presence, if you want to call 15 it, of HELLP at that time, or what she had at that time. I 16 will say ELLP, not HELLP. 17 Q. They never did the test to determine if she had 18 hemolysis, did she? 19 A. No. There was no mention in the peripheral 20 smear that she had hemolysis. So I will say she had ELLP 21 definitely. 22 Q. The reason you can't say she had HELLP is 23 because he didn't do the test to determine whether she had 24 hemolysis? 42 1 MR. HUMPHREY: He just mentioned a smear. 2 Other than that? 3 MR. HIRSHMAN: I'm not sure he mentioned it. 4 BY MR. HIRSHMAN: 5 Q. Are you telling me there was evidence in the 6 chart that she did not have a problem with hemolysis? 7 A. No. All I'm saying, at that time the lab tests 8 that were available suggested she had ELLP. 9 Q. So you're not taking the position -- 10 MR. HUMPHREY: Let him finish. 11 A. She had HELLP syndrome. It's not an issue. 12 Q. She had HELLP syndrome? 13 A. Yes. 14 Q. So you're not disputing that. That was 15 reasonably concludable by 3:50 or 4:00 in the morning? 16 A. She had severe preeclampsia. 17 Q. Before that? 18 A. Yeah. 19 Q. By the time the platelet results came back, by 20 the time the AST results came back, and by the time the ALT 21 results came back, all of which came back at around 2:50 in 22 the morning, it was obvious that she had HELLP syndrome, 23 correct? 24 A. Yes. 43 1 Q. Now, HELLP syndrome is obviously not the same 2 thing as preeclampsia, is it? 3 A. What do you mean? People try to differentiate 4 it. I always say, I don't know why people want to 5 differentiate. It is preeclampsia. 6 Q. HELLP syndrome -- we've just talked about how 7 many patients you have seen with HELLP and we talked about 8 how many patients with preeclampsia. If I'm not mistaken, 9 the number of preeclampsia was significantly larger than the 10 number of HELLP patients. 11 A. Yeah. Because HELLP is severe preeclampsia. 12 Q. We also discussed the number of severe 13 preeclampsia patients that you've seen. I don't think, by 14 virtue of those numbers, that it would be fair to say that 15 severe preeclampsia and HELLP syndrome are the same thing. 16 Maybe I'm wrong. Are you suggesting that they're the exact 17 same thing? 18 A. Again, I think -- you are try -- people try to 19 give what you call names to things. What really HELLP 20 syndrome is is preeclampsia with certain abnormal tests, if 21 you want to put it this way. 22 Q. You defined severe preeclampsia for us in a way 23 that included various combinations of hypertension and 24 proteinuria, thrombocytopenia. 44 1 A. I told you there are at least 15 different 2 criteria that makes severe preeclampsia. People, for 3 semantics, try to differentiate between the two. HELLP is 4 preeclampsia plus abnormal lab tests, is what it is. You 5 call it HELLP. It doesn't matter. 6 Q. You've read the deposition of Dr. Liu? 7 A. Yes. 8 Q. Do you feel that he understood what the 9 condition of HELLP syndrome was? 10 A. I'm not clear after reading his deposition. He 11 knew she had preeclampsia. He knew she had the blood 12 pressures and the urine protein. So he had all the 13 information to suggest she had severe preeclampsia. Then 14 she had abnormal laboratory tests. 15 Q. By reading his deposition, were you able to 16 conclude that he had a firm and acceptable understanding as 17 to what HELLP syndrome is? 18 A. I don't know how to answer this question, 19 because there are really many people who don't even consider 20 HELLP syndrome as anything, because they consider it 21 preeclampsia. 22 Q. Okay. 23 A. So this is why I really don't know how to 24 answer you, you know. Because after some few years, they 45 1 go -- many textbooks did not put the word HELLP syndrome 2 there because they say, you know, women with preeclampsia 3 are known to have some of these things. So it was really 4 given a name more than anything. 5 Q. It's not only been given a name, it's been 6 broken down into different classes about it by some people? 7 A. I will say there's only one group who have done 8 those classes. This is in Mississippi. 9 Q. You don't adhere to that methodology? 10 A. No. 11 Q. You don't classify HELLP syndrome as class one, 12 class two? 13 A. No. It doesn't really -- I always say these 14 are laboratory things. 15 Q. Now, from your review of the depositions and in 16 the medical records, can you tell me whether Mrs. Wright 17 suffered from epigastric pain? 18 A. Yes. 19 Q. Did she? 20 A. Yes. 21 Q. Did she suffer from blood-tinged urine? 22 A. Yes. 23 Q. Did she suffer from shoulder pain? 24 A. No. 46 1 Q. She didn't? 2 A. No. 3 Q. Did you see a nurse's notes regarding shoulder 4 discomfort? 5 A. She had shoulder cramps, not pain. 6 Q. So, in your way of looking at this, that was 7 not the type of sign or symptom that suggests a hepatic 8 hematoma? 9 A. No. Because the nurses said she gave her a hot 10 pad or something and it improved. This is not something 11 that you see as liver hematoma. It is mentioned as a 12 cramp. Nowhere in the chart the word pain is mentioned. 13 Q. What causes shoulder pain in association with 14 hepatic hematoma, the phrenic nerve is stimulated in some 15 fashion? 16 A. Well, you know, if you think that the nerve 17 supplied to the diaphragm has the same plexus that supplies 18 the right shoulder, muscles, all the way to the neck even -- 19 so if you have blood in the peritoneum, this will irritate 20 the diaphragm. 21 This is why we teach people, as when you are 22 leading with a patient suspecting ectopic pregnancy, 23 shoulder pain is one of the things to look for. So it's 24 really all about irritation of the diaphragm more than 47 1 anything. 2 Q. And what you're telling us is that your review 3 of the records suggest to you that this shoulder pain was 4 not pain at all, but rather just a cramp? 5 A. This is what's written. I'm not -- I don't 6 want to speculate. 7 Q. Let's assume for a moment that it was shoulder 8 pain rather than a shoulder cramp. Okay? 9 MR. HUMPHREY: The kind of pain that doesn't go 10 away with application of heat, Toby? Do you want to 11 assume that, too? 12 MR. HIRSHMAN: Let's find the records to it. 13 BY MR. HIRSHMAN: 14 Q. What I see is at 3:50 in the records? 15 A. Yes. 16 Q. Patient complains of shoulder cramp moving from 17 side to side, uncomfortable. Now, you've indicated that 18 there's some reference to a heating pad making the pain 19 going away? 20 A. Yeah. 21 Q. Where do you see that? 22 A. In the deposition. 23 Q. Of who? 24 A. The nurse. It was mentioned in two of the 48 1 depositions. The nurse who was with her. I think Nurse 2 Burton. Do you want me to show it to you? 3 Q. Yeah, if you would. 4 A. Yeah. You asked her this question, I'm sure. 5 It was mentioned, also, I think, in the nurse midwife's 6 also. 7 Q. I can find it. You don't have to find it for 8 me. 9 A. Here it says, I remember I massaged her for a 10 while and she said that it felt better. 11 Q. Okay. So you concluded from that that this was 12 not shoulder pain indicative of a phrenic nerve stimulation? 13 A. No. 14 You know, if she sees this patient, she will 15 have an irritation of the diaphragm; the other thing also 16 could be a mass under the diaphragm. This is where a 17 subcapsular liver hematoma is. 18 Really, it's just a referral pain to this 19 nerve. They would be screaming. 20 What is described here, the patient was moving, 21 thinking that this -- it was because of the position, which 22 is more consistent with a cramp. The patient is trying to 23 move from one side to side, to relieve as a cramp. 24 Q. Let's talk for a moment about the significance 49 1 of true shoulder pain in a patient with epigastric pain and 2 HELLP syndrome. What would be the significance of that? 3 A. It is one of the things that it might be 4 consistent with something under the diaphragm. It could be 5 blood in the peritoneum. 6 Q. That would be an indication for the performance 7 of a CT scan under those circumstances, would it not? 8 MR. HUMPHREY: Wait a second. Pain that does 9 not go away, where the patient is screaming? 10 MR. HIRSHMAN: Pain that does not go away. 11 BY MR. HIRSHMAN: 12 Q. Do you want to add, where the patient was 13 screaming? We'll add where the patient is screaming. 14 A. Yes. 15 Q. Pain that does not go away in the shoulder in a 16 patient with HELLP syndrome is an indication to perform a CT 17 scan? 18 A. Yes. 19 Q. That's what you teach residents who are being 20 trained under you, I presume? 21 A. Yes. 22 Q. Let's talk about when Dr. Liu first learned of 23 severe preeclampsia. Is it your understanding that that 24 occurred at about 1:45? 50 1 A. Yes. This is the first phone call. 2 Q. Is severe preeclampsia a condition that -- 3 let's put it this way. Did he come into the hospital when 4 he heard about the severe preeclampsia? 5 A. No. 6 Q. Was there an obstetrician available in the 7 hospital when he heard about this severe preeclampsia? 8 A. No. 9 Q. What are the dangers and risks associated with 10 severe preeclampsia? What can happen to a woman with that 11 condition? 12 A. A woman with severe preeclampsia, I will say 13 the number one risk is convulsion. The other risk would be 14 abruptio placenta. 15 Q. That's when the placenta separates from the 16 uterine wall, suffocating the child, or depriving the child 17 of oxygen and nutrients? 18 A. Yes. 19 Q. Okay. 20 A. The patient could bleed in her brain. I would 21 say probably these are the three serious things. 22 Q. So we can agree that severe preeclampsia is a 23 serious illness? 24 A. In some women, yes. 51 1 Q. It's an urgent situation? 2 A. I don't know. What do you mean by the word 3 "urgent"? I have had women with severe preeclampsia 4 pregnant for weeks. So you need to tell me what you mean. 5 Q. It's a situation that requires the presence of 6 a physician, is it not? 7 A. It requires all that is given by a physician. 8 This is really the most important thing. 9 Q. So you have no problem with Dr. Liu's decision 10 not to come into the hospital for this patient? 11 A. At what time? At 1:30? 12 Q. 1:45. 13 A. If he gave the right orders, no, really I don't 14 think it's a reason to come. 15 Q. So you have no problem with what Dr. Liu did at 16 1:45? 17 A. At 1:45, knowing this information and giving 18 the orders, is this -- the question -- the issue is not 19 whether you have a doctor or not. See, that availability of 20 the doctor is irrelevant. As does -- what the orders given 21 to manage the patient, this is what is more important. 22 You can have a doctor in the hospital and not 23 give the orders. He will then give them -- if he's in the 24 hospital, he will not give them at all. 52 1 Q. Did he give the correct orders at 1:45? 2 A. I will say no. 3 Q. And what did he not give that he should have 4 given? 5 A. He should have given -- started magnesium 6 sulfate. 7 Q. Right then? 8 A. Yes. 9 Q. Are you aware of a hospital protocol that 10 requires a physician to come to the hospital and examine the 11 patient before magnesium sulfate is given? 12 A. I'm aware of the hospital protocol that says 13 evaluate the patient. It doesn't say the physician has to 14 be there. 15 Q. So as you interpret that protocol -- and I 16 presume you've seen it? 17 A. Yes. 18 Q. You interpret it to mean that the evaluation 19 can be done by phone? 20 A. Yeah. I practice. I don't come to the 21 hospital. I can prescribe magnesium sulfate on the phone. 22 I think, you know -- do you want me to explain the situation 23 in this case? 24 Q. Certainly. 53 1 A. This protocol is written, if you aren't in the 2 hospital and the only people that are available in the 3 hospital are nurses, then the only way a physician can 4 evaluate the patient and know if he wants to -- in this 5 situation, you had a nurse midwife who really acts as a 6 physician in the hospital. And this is what we have here, 7 actually, at the University Hospital. We have nurse 8 midwives who can evaluate the patient. 9 The most important thing, this nurse midwife, 10 they work and their supervision is in collaboration with a 11 physician. So, really, the evaluation has already been 12 made. 13 He had all the information he needed to know if 14 he was present there. The issue in this case is what is the 15 response to the evaluation. 16 Q. And he didn't, as I understand it -- you tell 17 me if you interpret these records and the depositions the 18 same way as I interpret the events that unfolded. 19 Nurse Nuza concluded that magnesium sulfate 20 should be given. In fact, she wrote it in the chart. She 21 then called up Dr. Liu, and Dr. Liu told her that he didn't 22 want to give magnesium sulfate. Is that how you understand 23 it? 24 A. Correct. 54 1 Q. He was wrong in doing that, correct? 2 A. I say magnesium sulfate should have been given 3 in this case. 4 Q. And it should have been given then? 5 A. Yeah, at that time. 6 Again, once you make a diagnosis of severe 7 preeclampsia, as I said, the patient is at risk for having 8 convulsions. Then magnesium sulfate needed to be started. 9 This is what I said, this evaluation in this 10 case was done, because the nurse midwife really functioned 11 as an obstetrician. She does. She knows how to make 12 diagnosis. A regular nurse cannot make diagnosis. 13 This is the difference. This is why this 14 protocol was put. A nurse on her own cannot make 15 diagnosis. A nurse midwife can make diagnosis. That's the 16 difference between the two. 17 Q. All right. So the right evaluation was done, 18 but the wrong orders were given at 1:45? 19 A. I will say that was an omission of not giving 20 magnesium sulfate. 21 Q. And we've already indicated Dr. Liu learned of 22 HELLP syndrome at about 2:50? 23 A. Yes. 24 Q. And what are the dangers associated with HELLP 55 1 syndrome, same dangers we talked about with preeclampsia? 2 A. Yes. 3 Q. Plus more? 4 A. Plus, in this case, you have the issue of -- 5 with HELLP syndrome, you would have problems with the liver, 6 which is an additional thing. 7 Q. So it would be fair to say that once those labs 8 came back, she was found to be even sicker than was 9 previously thought? 10 A. I don't know. You know, again, you keep on 11 saying she is sicker. In my opinion, woman was severe 12 preeclampsia. They do much worse than some women who have 13 HELLP syndrome. 14 Again, this is why I don't like when people say 15 this is preeclampsia or HELLP. There are more women who 16 might die and have problem with preeclampsia than you have 17 with HELLP syndrome. 18 So, really, preeclampsia is a condition that's 19 serious when it's severe. 20 Q. Let's put it this way. Nothing that occurred 21 at 2:50 would reasonably allow a care provider to conclude 22 that this was not a sick woman? 23 A. You are right. At that time there were a lot 24 of information to suggest that she had severe preeclampsia 56 1 and she had involvement of her liver and she had low 2 platelets. 3 Q. Okay. 4 A. And she was hepatic. So he really had all the 5 information. 6 He requested lab tests which, in my opinion, 7 was a reasonable thing to do. He had all this information. 8 At that time he had all the information he needed to know 9 about this patient. 10 Q. So, as of that time, it's your understanding of 11 the records that Judy Nuza told Dr. Liu over the phone about 12 the results of the lab tests? 13 A. And blood pressures and the symptoms, according 14 to depositions. 15 Q. Did Judy Nuza ask Dr. Liu to come in as you 16 read the materials in this case? 17 A. Again, this is really -- I read these 18 depositions. It's a very difficult question to answer 19 because a nurse cannot ask a doctor to come in, 20 particularly when the doctor is her supervisor. 21 What she does, she communicated all the 22 information to him that he really needed to know. It's now 23 his decision whether he needs to be there. 24 And, ultimately, always tell people -- people 57 1 think that the presence of the doctor is important. It's 2 the information that's available and what the doctor does 3 with the information that's very important. 4 Dr. Liu had every information he needed to know 5 at that time from the nurse. He had the option to come if 6 he thought that the nurse is not communicating the 7 information to him that he wanted to know or he did not 8 think she is capable. 9 See, a nurse midwife is functioning as an 10 obstetrician, under the supervision of this physician. 11 Q. So it's your position that Dr. Liu did not have 12 any obligation to come into the hospital with this patient 13 when being seen by this nurse midwife? 14 A. No, I didn't say that. I didn't say he didn't 15 have an obligation. 16 Q. Okay. 17 A. All I'm saying is, Dr. Liu knew all the 18 information. At that time, yes, he should have come, 19 because now he has a lot of information that's showing him 20 that this patient has been observed, she had severe 21 preeclampsia, she's having all of these symptoms, and he 22 needs to make a decision what to do with this information. 23 But, I would repeat, whether he was in the 24 hospital or at home, he really knew everything he needed to 58 1 know. The issue in this case is that what to do with the 2 information. 3 Q. But as you've indicated, it's your opinion he 4 should have come in? 5 A. Yes. But, again, I keep on repeating, if he 6 came in, he had all the information he would ever get about 7 this woman. 8 Q. Okay. Did Dr. Liu ever learn prior to the 9 fetal bradycardia and the cesarean section about this 10 shoulder cramp? 11 A. No. 12 Q. He didn't, did he? 13 A. No. Even if he knew this information, I can't 14 say more than 99.9 percent it wouldn't have made -- because 15 he had all the information he really needed to know. 16 Now, his presence would have been important, 17 because if there were to be changes in the fetal heart rate 18 at that time, then the baby had to be delivered. 19 Q. And the sooner the better? 20 A. The nurse midwife cannot do a cesarean 21 section. This is really the only thing the nurse midwife 22 can't do. This is why they're required to work in 23 collaboration or supervision with OB/GYN, similar like a 24 family practice physician who does OB. 59 1 Q. So, obviously, once the fetal bradycardia 2 occurs, which I presume you would conclude was due to the 3 rupture of the liver capsule -- is that your opinion? 4 A. I will say something happened at that time that 5 resulted in reduced blood flow to the uterus that led to 6 this bradycardia. And most likely there was an abrupt 7 rupture in the capsule. 8 Q. The same thing that caused the fetal 9 bradycardia and caused the reduced blood flow to the 10 placenta also caused a reduced blood flow to Wanda Wright's 11 brain, correct? 12 A. No. It's not true. The reduction of blood 13 flow happened later on with the subsequent surgery. So it's 14 a combination of all of these things. Because if what 15 you're saying is true, this baby couldn't have been 16 survived, first. The second thing, this wouldn't have had 17 the Apgar scores that it had. 18 So really, a lot of things that happened to her 19 happened afterwards. 20 There is no way this baby could have been like 21 this, because usually what happened in this case, the mother 22 shunts the blood away from this splanchnic area. And the 23 uterus is considered a splanchnic area. 24 So this fetus being born in this condition 60 1 suggests this woman did not suffer at that time which you 2 are talking about. But she suffered later on. 3 Q. Did she ever recover consciousness after that 4 delivery? 5 A. No. 6 Q. Why didn't she recover consciousness? 7 A. She had reduced blood flow to the brain. 8 Q. Okay. Now, she was hypertensive, was she not, 9 up until the time she became hypotensive? 10 A. Yes. 11 Q. She was hypertensive up until the time that she 12 was hypotensive, because nobody reduced her blood pressure, 13 correct? 14 A. Correct. 15 Q. And there certainly were methods available to 16 reduce her blood pressure, were there not? 17 A. Yes. 18 Q. Labetalol is one drug that could have 19 effectively been utilized? 20 A. Hydralazine Labetalol. There are several 21 drugs. 22 Q. All those drugs are effective in almost all 23 cases in reducing blood pressure to more tolerable levels 24 within half an hour, correct? 61 1 A. Yes. 2 Q. Okay. Now, that wasn't done for Wanda Wright, 3 correct? 4 A. Correct. 5 Q. It should have been done? 6 A. Yes. 7 Q. And to not do it was a departure from 8 acceptable standards of care, wasn't it? 9 A. Yes. 10 Q. And it should have been done by Dr. Liu? 11 A. Yes. This is why I said he had all of the 12 information. It could have been ordered on the phone. 13 That's why I keep on saying, the presence of the physician 14 is not that relevant, because the information was all 15 available. 16 Q. So Dr. Liu never bothered to reduce her blood 17 pressure. And she then went from being hypertensive to 18 suddenly being hypotensive, correct? 19 A. Yes. 20 Q. Now, a woman with a blood pressure elevated as 21 high as Wanda's was, which was what, 212/1 -- 217/112 at one 22 point? 23 A. She had several. She had elevated blood 24 pressures. 62 1 Q. Yeah. What happens to a woman in that 2 condition, or to any person in that condition, is that the 3 brain, in attempting to deal with that hypertension, goes 4 into an autoregulative mode, doesn't it? 5 A. All brains have autoregulation. As we sit 6 here, we're autoregulating, all of us. 7 Q. But the brain does that in the face of 8 hypertension. This autoregulation means that the patient 9 attempts to reduce the blood pressure intracranially, in 10 order to prevent an edema from occurring in the brain? 11 A. No. Let me explain this to you what cerebral 12 autoregulation is. Blood flow to the brain remains constant 13 at the same arterial blood pressure. See, this is why in 14 this case it's not the systolic or the diastolic. The mean 15 arterial blood pressure was the issue. The mean arterial 16 blood pressure was high in this case. 17 Q. So what the brain did in order to deal with it, 18 elevated the mean arterial blood pressure to reduce the 19 amount of pressure and blood flow to the brain? 20 MR. HUMPHREY: Objection. I don't think that's 21 what he said. 22 A. Let me explain what cerebral autoregulation is. 23 Probably this is the best thing. 24 BY MR. HIRSHMAN: 63 1 Q. Okay. Go ahead. 2 A. Blood flow to the brain remains constant at 3 various mean arterial blood pressures. Below a mean 4 arterial blood pressure -- in this case we are talking about 5 a normal woman, which is different than somebody who's 6 hypertensive. We are dealing with a woman who is 7 normotensive. 8 Q. In the usual situation, she was normotensive? 9 A. Correct. Somebody like her, if the mean 10 arterial blood pressure drops below 60, then blood flow to 11 the brain will be reduced, which ultimately happened to her 12 later on. 13 Q. Won't be reduced? 14 A. Will be reduced. If it is between a mean 15 arterial blood pressure of about 60 to mean arterial blood 16 pressure of 130, big range, blood flow remains constant. 17 This is what we call cerebral autoregulation. 18 If you exceed this upper limit, then you have 19 what we call a stroke, which means you bleed in your brain, 20 or you develop hypertensive encephalopathy. 21 If you go below the lower limit, you develop 22 what we call hypoxic ischemic encephalopathy. She developed 23 the hypoxic ischemic encephalopathy and became hypertensive. 24 The problem was the low blood pressure which 64 1 led to her -- she suffered that after her liver ruptured. 2 Q. You did not believe she had hypertensive 3 encephalopathy? 4 A. No, she didn't. 5 Q. What is the mechanism by which the brain 6 provides this autoregulatory function? Is it vasospasm? 7 A. Yes. 8 Q. Is that what's happening? 9 A. Yes. It changes the tone of the blood vessels. 10 Q. So because of elevated blood pressure in Wanda 11 Wright's body, the vasculature to the brain reduces its -- 12 its capacity in order to reduce the amount of pressure 13 that's going to the brain? 14 A. Blood flow, not the pressure. Blood flow. 15 Q. Okay. 16 A. So, really, this is a mechanism to help her so 17 that she does not develop a breakthrough of the blood 18 vessels of the brain. Her CT scan did not show that. This 19 is why I'm trying to explain this to you. 20 What happened on her, because of the reduced 21 blood flow -- so her problem was in the lower end of it. 22 This is what I tried to explain to you. 23 This is why people faint. If you stand up for 24 a long time and you pool your blood in your legs, what 65 1 happens is, your mean arterial blood will drop, and as the 2 blood flow to the brain falls, you tend to faint. So when 3 you faint, you lie down, then blood flow and your blood 4 pressure will increase again. 5 Q. Now, where does this vasospasm occur? Is it in 6 certain anatomic structures or throughout the vasculature of 7 the entire brain? 8 A. No. This is just mostly in the blood vessels. 9 Usually the larger one and some of the middle ones. This is 10 it. It's just -- and then there goes a process of 11 constriction. 12 It's interesting. If you bleed in your brain, 13 the brain does the same thing. But the main reason it does 14 it, it tries to increase blood pressure to increase blood 15 flow to the brain. It's a very unique organ. It tries to 16 control the blood flow and what happens in the brain. 17 Q. So the vasospasm occurred in arteries, such the 18 a middle cerebral artery? 19 A. And smaller ones. 20 Q. And smaller ones, as well? 21 A. And really the area that's most susceptible is 22 what we call the watershed area of the brain. 23 Q. And how long does it take for that process, 24 that autoregulatory vasospasm, to reverse itself? 66 1 A. I don't understand your question. 2 Q. When the elevated blood pressure ceases to 3 exist, how long does it take for those vessels to stop 4 clamping down? 5 A. Oh, it depends. It varies. You know, for a 6 woman with preeclampsia -- this is why some of them, their 7 blood pressure will go down to normal in a few days. Some, 8 it might take a week. This is -- some of them, we give them 9 medicine and tell them, come back in a week and see what 10 will happen. 11 It's really variable. It's unpredictable. 12 Q. It's not instantaneous necessarily? 13 A. No. 14 MR. HUMPHREY: Outside of the presence of 15 hypotension, though? 16 BY MR. HIRSHMAN: 17 Q. You understand what I'm asking you? 18 A. Yeah. See, in this case, the problem has been 19 the hypotension. This woman developed what I call ischemic 20 hypoxic encephalopathy. She did not develop hypertensive 21 encephalopathy. 22 Q. My question to you, I guess, is, once the 23 bleeding occurred and Wanda became hypotensive, can you tell 24 me how long it took before the vessels in her brain stopped 67 1 clamping down and causing a vasospasm? 2 A. I'm not clear what you're saying, now. The 3 issue in this case, the mean arterial blood pressure dropped 4 a certain level. So, really, blood flow got reduced. The 5 brain -- the cerebral autoregulation, it got knocked off. 6 It doesn't work anymore. 7 Q. Are you telling me as soon as the rupture 8 occurred and her hypotension came into play, that her 9 cerebral vasculature immediately stopped clamping down? 10 A. It's not stopped clamping down. All I'm saying 11 is that this mechanism is working at certain levels. Once 12 the blood pressure develops below a certain level, it 13 doesn't work anymore. 14 Q. So that's what I'm asking you. Once her blood 15 pressure went down to normal and then subnormal levels, are 16 you telling me that her brain stopped vasospasms instantly? 17 A. It's not instantly. You take -- it takes some 18 time of reduced blood flow to the brain to produce the 19 ischemic changes. So it's not an instantaneous thing. See, 20 remember -- 21 Q. Are you suggesting to me -- 22 MR. HUMPHREY: Let him finish. 23 A. What we are talking about, as I told you 24 before, the brain tries to protect itself. The mother tries 68 1 to protect itself. The human being, there are three areas 2 that are important to survive: the brain, the heart, and 3 the adrenal gland. 4 In that situation, when the body requires 5 oxygen and blood, it undergoes shunting mechanisms for the 6 blood to these areas and to sacrifice everything else. 7 This is why I said the uterus is one of 8 the areas -- it's called splanchnic. It's not needed for 9 life. So, really, the effect on the fetus will be before 10 you see the effects on the mother. 11 Q. Let me ask the question simply, then, and 12 straightforwardly. Is it your opinion that the preexisting 13 hypertension in no way exacerbated the cerebral effect of 14 the subsequent hypotension? 15 A. Yes. 16 Q. That's your opinion? 17 A. I can tell you in this case, if this woman bled 18 in her brain, then antihypertensive therapy would be 19 important. If somebody would have lowered her blood 20 pressure, you would have seen the effects on the fetus. The 21 fetus would have been much worse. 22 Because, really, this hypertension was a 23 compensating mechanism in this woman. But it was at such a 24 level, it needs to be lowered to prevent her from bleeding 69 1 in her brain. But this wouldn't have been good for the 2 fetus. 3 Q. Are you trained in neurology? 4 A. No. 5 Q. And when it comes -- 6 MR. FRASURE: Trained in what? 7 MR. HIRSHMAN: Neurology. 8 BY MR. HIRSHMAN: 9 Q. When it comes to describing the mechanisms of 10 blood flow in the brain and the autoregulatory mechanisms of 11 the brain and the effects of hypotension on the brain, would 12 you defer to a neurologist? 13 MR. HUMPHREY: Objection. He just answered 14 your questions on all of those issues. 15 A. Wait, wait, wait. 16 MR. HIRSHMAN: I'm asking him a question as to 17 whether he would defer to a neurologist. Never heard 18 that question before in a deposition? 19 MR. HUMPHREY: He did not defer to a 20 neurologist. He just told you for the last 20 21 minutes what his opinions were. 22 BY MR. HIRSHMAN: 23 Q. Are you a neurologist? 24 A. No. 70 1 Q. Do you defer to a neurologists when it comes to 2 injuries to the brain and their -- 3 A. In pregnancy, no; postpartum, no. I have more 4 experience than any neurologist in this. I have written all 5 the work and experience in pregnancy, stroke postpartum, 6 all the cerebral pregnancy, yes. 7 So if you are talking trauma, no. If you are 8 talking pregnancy, postpartum, believe me, I don't defer to 9 any of those people to come and work with me. 10 Q. Do you have an opinion as to whether there was 11 a vasodilation function that occurred in this hypertensive 12 episode as opposed to a vasospasm function? 13 MR. HUMPHREY: Before the hypotension? 14 BY MR. HIRSHMAN: 15 Q. That's part of the hypertensive episode. 16 A. I don't understand the question. 17 Q. It's my understanding -- you correct me if I'm 18 wrong -- that there are two processes that may come into 19 play as the brain tries to deal with hypertension. It's 20 thought by some that the brain and the vessels to the brain 21 attempt to achieve a vasospasm? 22 A. At the beginning. 23 Q. It's thought by others that there is a 24 vasodilation that occurs? 71 1 A. Later on. 2 Q. Okay. 3 A. This is what we call hypertensive 4 encephalopathy. 5 Q. Are you able to rule out that vasodilation 6 process as having been something that occurred in this case? 7 A. I still don't understand your question. You 8 know, there is nothing called vasodilation. 9 What happened when you are talking about 10 hypertensive encephalopathy, as you reach a certain level 11 where you have forced flow of this blood and then the blood 12 vessel would relax -- this is probably what they are talking 13 about -- and then you've got flow oozing -- you have injury 14 to the endothelial lining of the blood vessels. 15 Q. Are you able to tell me that that did not occur 16 in this case? 17 A. I will say very unlikely, yes. As a 18 possibility, yes. But I will say it very, very unlikely. 19 Q. And you say it's unlikely on what basis? 20 A. Because if you had hypertensive encephalopathy, 21 you tend to have a lot of changes before. There is no 22 evidence -- again, nobody checked it, so we don't know, 23 whether this patient developed a lipidemia, for example, 24 which is one of the manifestations. 72 1 There is no evidence I can see in the medical 2 record that this patient had seizure, which you see with 3 hypertensive encephalopathy. 4 Q. You also see seizures with a hypoxic ischemic 5 encephalopathy? 6 A. But it takes a longer time. This is the 7 difference. The hypertensive encephalopathy is an immediate 8 effect. You will see it within a short period of time. The 9 effect in the brain from the hypoxic ischemia, it might take 10 some time to show. The problem is the CT scan was done on 11 the 20th of March, and the events happened on the 17th of 12 March. 13 Q. Uh-huh. 14 A. Already we know she had cerebral edema. 15 Q. Okay. 16 A. Now, if a CT scan was done closer to the event 17 and showed the cerebral edema, then I will say most likely 18 could have been what you are describing. 19 Q. Okay. 20 A. The problem is, the CT scan was done three days 21 after the events happened, and this is exactly what it 22 takes. After you have this hypoxic ischemic injury -- and 23 you should know this if you do baby cases. When you have 24 injury to the baby's brain at the time and when you do the 73 1 CT scan -- really, the cerebral edema, it takes at least 2 three days to -- 3 Q. Go ahead. 4 A. So, really, in this case, I would say, based on 5 my experience, this is more likely a hypoxic event, ischemic 6 event, rather than a hypertensive effect. This is really 7 what we are arguing about. 8 Q. So we can agree that the radiographic findings 9 on the CT scan that were done on the 20th are equally 10 consistent with hypoxic ischemic encephalopathy and 11 hypertensive encephalopathy? 12 MR. HUMPHREY: Objection. I don't think he 13 said that. 14 A. I didn't -- all I said, she had cerebral 15 edema. You will see on both of these. The problem is the 16 CT scan was done three days later. The clinical picture is 17 not as typical. 18 We know that this patient changed -- with the 19 change that happened, with the rupture of the liver and the 20 things that happened to the fetus, they are inconsistent 21 with the hypertensive encephalopathy. 22 Q. So the radiographic evidence does not allow you 23 to distinguish between the two. Fair statement? 24 A. No, fair statement. 74 1 Q. In this case because it was taken three days 2 after the delivery? 3 A. Correct. 4 Q. You are making a determination as to which of 5 these two entities we are dealing with by virtue of your 6 examination of the clinical findings? 7 A. And my experience, because I am the person who 8 wrote most of the literature on this and pregnancy and 9 postpartum. The neurologists deal with nonpregnant 10 individuals. I have here information of having the fetus, 11 the fetal heart rate. I'm putting all of this information 12 together. 13 Q. So it's your contention, then, that the 14 hypertensive state that Wanda Wright had and which was never 15 properly treated was irrelevant to her injuries? 16 A. Yes. 17 Q. Can you think of any medical reason why Mrs. 18 Wright couldn't have been transferred to a facility with a 19 greater ability to deal with her maternal and pregnancy 20 complications? 21 MR. HUMPHREY: Objection. 22 A. I don't know. I have a problem with your 23 question, can you think of any medical reason. 24 You see, the medical reason is left to the 75 1 judgment of the physician who is managing her. When a 2 decision is made to transfer a patient, the decision is made 3 by the physician, based on their judgment and evaluation. 4 Q. Do you know how close the closest hospital was 5 that could have accommodated Wanda Wright as a tertiary care 6 center in Cleveland, Ohio? 7 A. I don't know. 8 Q. Are you familiar with University Hospitals? 9 A. Yes. 10 Q. That would have been a tertiary care facility 11 that would have been in a position to properly look after 12 Wanda Wright, would it not? 13 MR. HUMPHREY: Objection. 14 A. It depends whether there is a reason to 15 transfer the patient or not. 16 BY MR. HIRSHMAN: 17 Q. Let's put it this way. You get transfers from 18 200 or more miles away for patients that present with HELLP 19 syndrome, correct? 20 A. Yeah. But it doesn't mean I get all the 21 transfers. The decision to transfer a patient is made 22 really by the physician who's managing the patient. 23 Q. We know this much. Dr. Liu didn't make that 24 decision, did he? 76 1 A. He didn't make the decision to transfer her. 2 Q. He didn't even bother to come in, did he? 3 A. He didn't come in. You are right. 4 Q. You sure wouldn't have left a patient like 5 Wanda Wright in the hands of a midwife, with HELLP syndrome 6 and severe preeclampsia, would you? 7 A. I leave these patients with nurses regularly. 8 This is not the issue in this case. The issue is -- 9 Q. You leave these patients with nurses in 10 hospitals where there are residents who are also available, 11 correct? 12 A. No. I have been to hospitals where there were 13 no residents. The most important thing, the orders you give 14 and the management. You know, being present isn't an issue, 15 is that you need to make decisions about treatment. 16 In this case, what's unique -- all what you 17 need, all the information, you have, and everything he 18 needed to know on this woman. 19 Q. So far, we've identified two departures from 20 acceptable standards of care on the part of Dr. Liu, haven't 21 we? 22 A. Correct. 23 Q. He failed to give magnesium sulfate in a timely 24 fashion? 77 1 A. Yes. 2 Q. And he failed to give antihypertensive 3 medication in any fashion, correct? 4 A. Correct. 5 Q. Do you have any other criticisms of Dr. Liu, 6 other than those? 7 A. I think really those are the two things. 8 Everything else -- he initiated the process of delivery, 9 which, at 37 weeks, it should have been done. 10 Q. Because 37 weeks is essentially term? 11 A. Yeah. 12 Q. There weren't any issues in this case relating 13 to the need to have this baby spend more time in utero in 14 order to develop? 15 A. Correct. Even if it was 34 weeks, should have 16 been delivered. 17 Q. And we've already discussed how the one 18 thing -- even you will concede this. The one thing that a 19 physician can do that no one else can do is deliver the baby 20 by cesarean section? 21 A. Definitely. This is where a physician becomes 22 important. 23 Q. It becomes important for a physician to be 24 present when you're dealing with a high risk situation so 78 1 that that cesarean section can be done in the most timely 2 fashion possible? 3 A. Correct, that's right. I agree with you 4 100 percent. 5 Q. To the extent that a delivery by cesarean 6 section and, therefore, the discovery in this case -- it 7 wasn't until the delivery of the cesarean section that the 8 discovery of the hepatic rupture occurred, right? 9 A. Correct. 10 Q. If that delivery had been performed earlier, 11 the discovery would have been made earlier, correct? 12 A. This is going to be a very difficult question 13 to answer, because we don't know when the largest amount of 14 blood was coming in the peritoneum. We know that when they 15 opened her they saw a lot of blood. They suspected it. 16 Now, if they -- if this was done 15 minutes 17 before that, I will say probably the same. 30 minutes, I 18 cannot answer it. It's very difficult. 19 Q. Let's make an assumption, then. You don't have 20 to agree with it or disagree it. I'm going to ask you to 21 make an assumption. 22 A. I agree with you. Whoever, it is going to be a 23 speculation. There is no data to time this. 24 Q. I want you to assume -- let's start here. 79 1 You've looked at the fetal heart monitoring strip? 2 A. Yes. 3 Q. When did the bradycardia begin? 4 A. If I was managing this patient, standing next 5 to her, I will say somewhere about 4:30, 5:00. 6 Q. That's when the decision should have been made 7 to do a C-section? 8 A. Or made the decision usually -- the definition 9 of bradycardia has to be ten minutes. So I will say a 10 decision for C-section would have been at -- after you do 11 your evaluation and the resuscitation measures and 12 evaluation. 13 So you would have done, you know -- once I make 14 a diagnosis of bradycardia, I would move the patient to the 15 operating room, that's what I would have done, and then 16 tried to find a reason why the bradycardia is there. 17 We know that this patient was receiving 18 Cervedil. This is a medication that has been associated 19 with hyperstimulation. 20 So the first thing I will do is, I will try to 21 remove it, give the patient oxygen, check her, make sure 22 there isn't a prolapsed cord. If all of this, then a 23 C-section should be made. 24 So I will say somewhere about 4:45 I would have 80 1 moved the patient to the operating room and start all what I 2 told you about. Because we really know that she was 3 receiving a medicine that could lead to what she had. 4 Q. When was the Cervedil removed? 5 A. It's very difficult to tell from the records at 6 what time exactly. I couldn't delineate it well. 7 Q. Let me ask you about this fetal monitoring 8 strip in the period of time from 4:20 to 4:30. What's going 9 on there? 10 A. Okay. 11 MR. HUMPHREY: Do you have a panel number? 12 MR. HIRSHMAN: 39910. 13 A. I see. 14 BY MR. HIRSHMAN: 15 Q. 39991 and -- 16 A. On 4:20, I wouldn't have really recognized 17 anything, because I can see the variability is fine. 18 Q. Uh-huh. 19 A. There is some acceleration. So that wouldn't 20 concern me at all. 21 MR. HUMPHREY: Tell him what panel number you 22 were looking at when you said that. 23 BY MR. HIRSHMAN: 24 Q. 39910? 81 1 A. 908, 9909. It is the page afterwards you want. 2 Q. What you were just talking about is 39908 and 3 39909. 4 A. Okay. 5 Q. Let's move on to 39910. What do you see there? 6 A. What I'm seeing here, I'm seeing that the fetal 7 heart rate is changing. I cannot comment on panel 39910, 8 because it not continuous. It's being interrupted. 9 So the first thing at this time I would 10 suspect, probably the external fetal monitor is not picking 11 well. Because you have to think of that -- this is really 12 an ultrasound transducer. 13 On the next one, which is 39911, there are what 14 I call variable decelerations. 15 Q. Variable decelerations? 16 A. Yes. 17 Q. Okay. 18 A. They go down to about 75, then it goes back to 19 normal and then abrupts again. So you have at least two 20 variable decelerations. 21 Q. 39912? 22 A. Yes, I cannot evaluate, because I do not see a 23 reading recorded from this external. I think there is a 24 deceleration right around 4:30, but the fetal heart rate 82 1 picks up again. 2 Then, after that, I will say on panel 39914, I 3 see variable decelerations again. And then you start what 4 we call the bradycardia. 5 Q. The bradycardia starts right at 39914? 6 A. Yes. 7 Q. That comes back up? 8 A. Yeah. So, really, if I was looking at this, I 9 would have thought that there is some type of a cord 10 pattern. You have these variables, and then it has dropped, 11 suggesting that there is a cord that has dropped. 12 This is why I would have said I would have 13 taken the patient to the operating room and started the 14 maneuvers I mentioned before. 15 Q. If you were in the hospital, what time would 16 you have been able to deliver this child? 17 A. Okay. Let's say I would have done the pelvic 18 exam, ruptured the membranes, and put a scalp electrode so I 19 would get, really, a direct tracing, which is what happened 20 in this case. 21 I think the nurse ruptured the membrane right 22 around 4:50. I see a note there. Before that, they gave 23 her the oxygen. So I will say I will have started the 24 section somewhere around that time period. 83 1 Q. 4:50? 2 A. Yeah. 3 MR. FRASURE: Does that mean cut or -- just 4 for clarification. 5 BY MR. HIRSHMAN: 6 Q. That's the first incision, correct? 7 A. Well, you know, she's already in the operating 8 room. I assume the anesthesia would be in the operating 9 room. Then they have to scrub the patient. 10 So probably I would say the incision would have 11 been made around 4:55, because the anesthesiologists are 12 going to set all what they need. Meanwhile, I probably will 13 be scrubbing. 14 Then they need to give her oxygen before. They 15 have to visualize her larynx, put the tube in, so on. 16 So, really, the incision would have been made 17 before 4:55 -- 18 Q. All right. 19 A. -- if I was present there. 20 Q. This is where things start speeding up. I 21 start looking at things and they sound familiar. 22 MR. HUMPHREY: That's encouraging, Toby. 23 (Off the record.) 24 BY MR. HIRSHMAN: 84 1 Q. You've written a report. In it, you've -- 2 irregardless of your report, is it fair to say that you have 3 no criticisms of Nurse Burton in this case? 4 A. Absolutely. I really think Nurse Burton did 5 everything she can do as a nurse. There's absolutely 6 nothing I can see in this medical record that she failed to 7 do that has contributed to anything in this case. 8 Q. I'm going to mark this as Exhibit 1-A and 1-B. 9 I'm going to show them to you once everyone else has had a 10 chance to look at it. 11 (Plaintiffs' Exhibits 1-A and 1-B were marked 12 for identification.) 13 MR. HUMPHREY: Let me -- before you ask any 14 questions on this, Toby, I'm going to interpose my 15 objections on any questions relating to what's on the 16 record marked as 1-A and 1-B, record of warning or 17 disciplinary action of Beverly Burton. I believe 18 that it's privileged. It's not relevant. 19 But in order not to prevent you from asking 20 questions, I don't want to waive any objections I 21 have to this exhibit. 22 MR. HIRSHMAN: That's fine. 23 MR. HUMPHREY: Would you give the doctor a few 24 minutes to read over that? 85 1 THE WITNESS: Do I really have to read this? 2 MR. HUMPHREY: Yes, please. 3 THE WITNESS: It's irrelevant. 4 BY MR. HIRSHMAN: 5 Q. You've never read it before? 6 A. No. Okay. You want to ask a question. 7 Q. First question, you've had an opportunity to 8 read what has been marked as Sibai Exhibits 1-A and 1-B? 9 A. Yes. 10 Q. You've just had a chance to read them now? 11 A. Yes. 12 Q. Have you ever seen them before this very 13 moment? 14 A. No. 15 MR. HUMPHREY: Just so I don't have to keep 16 interrupting, just a continuing objection to these 17 exhibits -- 18 MR. HIRSHMAN: Okay. 19 MR. HUMPHREY: -- and questions. 20 BY MR. HIRSHMAN: 21 Q. And was your opinion before you read this 22 document that Nurse Burton's care and treatment was 23 appropriate? 24 A. Yes. 86 1 Q. And I take it it's still your opinion? 2 A. Oh, definitely. I don't see any of these 3 things, really -- 4 Q. Okay. 5 A. -- as relevant to my opinion. Do you want me 6 to address each one of them? 7 Q. No, no. 8 How about Judy Nuza? Do you have any opinions 9 as to whether she departed from acceptable standards of care 10 for a nurse midwife? 11 A. No. I think she acted based on whatever 12 collaboration and agreement she had with these physicians. 13 She acted under their supervision. 14 There was some discussion about whether she can 15 prescribe medications or not. And she said that there was 16 some verbal agreement between the two that there are certain 17 medications she can prescribe. 18 She even suggested giving magnesium sulfate, 19 but she couldn't -- the doctor had to institute this. 20 Q. And it's your opinion that she had no 21 obligation to affirmatively request that Dr. Liu come into 22 the hospital? 23 A. No. As I said before, him present before the 24 bradycardia was not an issue. Because, in my opinion, she 87 1 did an excellent evaluation of the patient. She conveyed to 2 him all the information that he really needed to know. 3 Q. Okay. 4 A. Whether she had the capability -- with him 5 being her supervisor, she cannot order her supervisor to 6 come. 7 She did everything which I think she was 8 capable of doing to give him all the information, to explain 9 to him what -- the diagnosis the woman had. 10 Q. Okay. How about Dr. Gyves? Do you have any 11 opinion as to whether Dr. Gyves' care and treatment 12 comported with acceptable standards of care? 13 A. I think he did more as needed. When he was 14 called, he came immediately. 15 Q. So he did not depart? 16 A. No. 17 Q. Now, do you have any opinions as to whether or 18 not Wanda Wright contributed, through her own negligence, to 19 her injury and ultimate death? 20 A. Yes. 21 Q. What is your opinion? 22 A. She didn't. 23 Q. Would you agree that, in the face of a ruptured 24 hepatic subcapsular hematoma, that time is of the essence in 88 1 performing surgery? 2 A. I'm trying to see how to answer this. Other, 3 really, than packing and giving blood, I can't see what a 4 surgery can do for a ruptured liver hematoma. So I think 5 what's needed is hemodynamic stability of the patient, is 6 the essence. It's not really the surgery. 7 Q. So what you're, in essence, saying, is that 8 when confronted with a subcapsular hematoma of the liver in 9 a HELLP syndrome patient, the cards are all dealt and 10 there's nothing that physicians can do to change the 11 outcome? 12 A. When they rupture? 13 Q. Correct. 14 A. I think the supportive care is the most 15 important thing. Indeed, many of these women die because of 16 the complications, rather than from the actual rupture 17 itself. 18 Q. So there is something that can be done? 19 A. Really, the supportive care. 20 Q. When you say "supportive care," what does that 21 entail? 22 A. Supporting their blood pressure. If they 23 develop ARDS, you need to take care of ARDS. If they have 24 renal failure, you need to put them on dialysis. Take care 89 1 of their nutritional needs and so on. This is the 2 management. 3 So the patient will not actually die because of 4 the rupture. They die from the complications. 5 Q. So if I understand you correctly then, what 6 you're saying is that whether you operate early or late 7 doesn't really make much of a difference? 8 A. Depends whether you have blood -- now, the 9 operation, if you find -- how can I put this? A bleeder, 10 that's some measure you can take care of, it might be 11 helpful. 12 My experience has been, in this condition, it's 13 just like opening a fountain of water. You cannot put 14 sutures because the liver is so friable. When you put the 15 sutures there, it just cuts through. 16 You try to coagulate and try to slow down the 17 bleeding, and then you pack it down and give them blood and 18 blood products. This is really where the surgery might be 19 helpful, that the packing might slow down the bleeding and 20 let them live enough to start the healing of the liver and 21 to keep on giving them blood and blood products. 22 Q. So this much can be done as a result of 23 diagnosis and surgery? You can find the bleed, you can pack 24 the liver, and thereby slow down the bleed? 90 1 A. And clear the peritoneum from blood. Because 2 what happens, again, in my experience, when the abdomen gets 3 distended, they are at risk for sepsis. 4 The other thing they are at risk for is that 5 they start having problems breathing and this might 6 contribute to their respiratory problem. This is where the 7 surgery might be helpful in this regard. 8 Q. So by stopping the bleeding, by packing -- 9 A. Slowing the bleeding. You cannot stop it. 10 Q. Slowing the bleeding by packing? 11 A. Yes. You cannot stop. 12 Q. Replacing the blood? 13 A. Yes. 14 Q. With blood products? 15 A. Yes. Correct. 16 Q. Cleaning the abdomen to hopefully prevent an 17 infection from forming? 18 A. Yes, uh-huh. 19 Q. With the hopeful prevention of resulting ARDS? 20 A. The prevention of ARDS has to do with 21 prevention of abdominal distention with blood inside. They 22 cannot breathe normally. Really, they cannot move their 23 lungs normally. 24 Q. So these treatment measures that we've just 91 1 mentioned, are you suggesting that they really have no 2 beneficial effect on patients? 3 A. I'm not understanding what you say. What 4 treatment? Are you just talking -- 5 Q. We just talked about packing? 6 A. Yes. 7 Q. We talked about providing blood products? 8 A. These are helpful. I didn't say they're not 9 beneficial. 10 Q. And cleaning the abdomen? 11 A. Yes. 12 Q. Those are all things that are done in order to 13 benefit the patient and increase their chances of intact 14 survival? 15 MR. HUMPHREY: What does that mean? 16 A. What does it mean? This is what I'm saying. 17 MR. HUMPHREY: What is intact survival, 18 survival with no morbidity? 19 BY MR. HIRSHMAN: 20 Q. Do you understand the question? Is it that 21 difficult a question? 22 MR. HUMPHREY: You need to answer the question. 23 A. I can't -- sorry. 24 MR. HUMPHREY: Just -- I'm asking you the 92 1 question, so it's clear on the record, what you mean 2 when you say "intact survival." 3 MR. HIRSHMAN: Bill Clinton might have trouble 4 with that question. I don't think Dr. Sibai does. 5 MR. HUMPHREY: If you understand what intact 6 survival means, answer the question. If you don't -- 7 A. For me, survival; not intact survival. The 8 issue is whether the patient's going to live or die, 9 because she's still going through all of these problems. 10 The likelihood of these problems happening would be reduced, 11 the ARDS, renal failure, and so on. 12 If the woman has had abdomen filled with blood, 13 she cannot breathe normally. You need to remove it. 14 If she has something that's under the diaphragm 15 and irritating it every time she breathes, it hurts, she's 16 not going to be breathing. It's shallow breathing. This is 17 where the surgery would help. 18 It's not something that is -- if you've done it 19 within 15 or 30 minutes. This is something ultimately you 20 have to do to prevent this from happening. So we're not 21 talking about 15 minutes, 30 minutes, or an hour or two 22 hours. 23 Q. So, essentially, timing is not a major issue 24 here? 93 1 A. No. The blood and blood products is what is 2 needed and supportive care. This is why, in my experience, 3 some of these women, they survive; some of them, they die. 4 The last one, actually, she was in the 5 hospital. We had all of the blood and everything. I had 6 the surgeon. Everything was ready. Ultimately, she died 7 from the complications. 8 This is why when you read about HELLP syndrome, 9 they do not die from the ruptured liver. They do from the 10 complications. This is the key point. 11 Q. Let's assume a CT had been done on Wanda 12 Wright. Let's assume it had been done at 2:50 in the 13 morning, 3:00 in the morning. 14 A. There is no way in the world you could have 15 done a CT at 3:00 in the morning, not even here in this 16 hospital. There is no way. At Columbia, there is no way 17 they would have done the CT scan in the morning. There is 18 no way. 19 Q. Let's assume that it been done at 3:00 in the 20 morning. Do you have an opinion as to what it would have 21 revealed? 22 MR. HUMPHREY: Objection. Go ahead and answer 23 if you can. 24 MR. FRASURE: Are you asking him to assume that 94 1 it was done, or it should have been done? 2 MR. HIRSHMAN: Just assume that it was done. I 3 haven't asked him whether it should have been done. 4 He seemed to have given me his opinion. 5 A. They have no indication to do the scan at 3:00. 6 BY MR. HIRSHMAN: 7 Q. Now, having told me there is no way there would 8 be a CT scan at 3:00, tell me what a CT scan of the liver 9 would have shown of the liver at that time? 10 A. It would have shown a liver hematoma. 11 Q. And, presumably, any CT scan done subsequent to 12 that would have also shown a liver hematoma? 13 A. Yes. 14 Q. And if they were done serially, you probably 15 would have been able to document an expanding liver 16 hematoma? 17 A. See, what you're talking about, you don't do it 18 every hour. There would have never been a second one. It 19 would have ruptured by then. 20 If the first CT scan was done at 3:00, the next 21 one wouldn't have been until about 6 or 12 hours later. So, 22 really, she would have ruptured by then. So this woman 23 would have never benefited from the CT, period. 24 Q. If a CT was done -- do you see any indications 95 1 in this chart for the performance of a CT scan? 2 A. No. If I was managing her, I wouldn't have 3 obtained the CT scan. 4 Q. And you wouldn't have done it for the liver 5 discomfort that we've discussed for the reasons you've 6 already mentioned? 7 A. Yes. 8 Now, in addition to being a HELLP syndrome 9 patient, Wanda had a number of other risk factors for a 10 hepatic hemorrhage, didn't she? 11 A. I don't understand your question. The only 12 risk for hepatic hemorrhage is HELLP syndrome and 13 preeclampsia. I don't understand what else. 14 Q. Are you of the opinion that advanced maternal 15 age constitutes a risk factor in a woman with HELLP syndrome 16 for a hepatic hemorrhage? 17 A. I thought we said the risk factor is HELLP and 18 understanding -- the maternal age is irrelevant. 19 Q. I'm asking you to look at the universe of women 20 with HELLP syndrome. 21 A. Yes. 22 Q. Are you of the opinion that advanced maternal 23 age constitutes an additional risk factor? 24 A. No. 96 1 Q. Are you of the opinion that multiparity 2 constitutes an additional risk factor? 3 A. No. These are risk factors for the HELLP and 4 preeclampsia. I think this is probably what -- has nothing 5 to do with the liver rupture. 6 Q. You've never heard anyone express the view that 7 advanced maternal age and multiparity are additional risk 8 factors? 9 A. Who, where? 10 Q. You've never read that in the literature? 11 A. I don't know. I wrote most of the literature. 12 Q. You didn't write it all. 13 A. I'm saying, based on my experience, which is 14 the largest, I can assure you that maternity age and 15 multiparity are more or less related to HELLP syndrome when 16 it comes to preeclampsia. 17 Q. And my next question to you was, have you read 18 anywhere in the literature that there are other folks who 19 deal with this entity? 20 A. You're telling me anywhere -- then you are 21 talking anyplace in the whole world, you know? 22 Q. I'm asking you whether or not this has ever 23 been an issue that you've heard discussed before? 24 A. No. 97 1 Q. Or read or discussed before? 2 A. No. 3 Q. When do you believe the hepatic hemorrhage 4 began? 5 MR. FRASURE: What was the question, Toby? 6 MR. HIRSHMAN: I asked him when he believes the 7 hepatic hemorrhage began. 8 BY MR. HIRSHMAN: 9 Q. Do you have an opinion on that? 10 A. I can tell you that she came with hepatic 11 hemorrhage. 12 Q. Into the hospital? 13 A. Yes. 14 Q. Okay. 15 A. When before, I can't tell you that. It would 16 be speculating. The main reason -- as I keep on saying, 17 there are many reasons with HELLP syndrome. And if they 18 have an hepatic hemorrhage we don't know about, we don't do 19 scans on. 20 Q. Did she have a coagulopathy prior to her 21 delivery? 22 A. All I can tell you, she had low platelet count. 23 Q. You don't know whether she had a coagulopathy 24 because no fibrin studies or DIC -- I mean, no D-dimer 98 1 studies were done, no fibrinogen studies? 2 A. I would say fibrinogen. D-dimer, I would not 3 use. I can't answer this without fibrinogen. 4 Q. So she may or may not have had a preexisting 5 coagulopathy prior to her delivery? 6 A. I will say if she had it, it might be only 7 laboratory. It's not clinical. Because when they made the 8 incision in her uterus, nobody commented. So I will rule 9 out DIC by at least 90 percent. 10 Is it possible she had it 10 percent? Yes. We 11 know she had infusions. Nobody commented about this. She 12 did not bleed from her nose or her gums. So I can tell you 13 I will rule out DIC in her more than 90 percent. 14 Q. Do you have an opinion as to whether she 15 developed DIC after the delivery? 16 A. Yes. All of them will develop DIC after the 17 rupture. 18 Q. Okay. 19 (Off the record.) 20 BY MR. HIRSHMAN: 21 Q. How much am I paying you for your time? 22 A. Are you paying -- 23 Q. This might impact the length of my questions. 24 A. You are paying me $1500. You have got 25 more 99 1 minutes. 2 Q. Is that what it is, $1500? 3 A. For three hours. 4 Q. Okay. Did you read Dr. Liu's deposition where 5 he talked about overshooting as a potential risk of 6 antihypertensive medication? 7 A. Yes. 8 Q. What is overshooting? 9 A. What happened, there are some women who have 10 severe preeclampsia who have severe plasma volume 11 depletion. When you give them a vasodilation, like 12 Hydralazine in this case, they have a precipitous drop in 13 blood pressure. Because, really, the way they are behaving, 14 even though their blood volume is contracted because their 15 blood vessels have constricted, there's a feeling that it's 16 adequate. 17 If you go and vasodilate these blood vessels so 18 you increase the amount of pipe, then the blood pressure 19 will suddenly drop. This leads to distress on the fetus. 20 That's what he's talking about. 21 Q. So if one were to overshoot, one could cause 22 injury to the fetus? 23 A. And to the liver at the same time also. 24 Q. And to other organs? 100 1 A. And the kidneys. 2 Q. And the brain? 3 A. And the brain. These are really the areas. 4 Q. Obviously, the way you avoid that is by 5 titrating carefully? 6 A. You give smaller doses. 7 Q. So that's not a sufficient reason for not 8 giving about hypertensive medication in a patient like Wanda 9 Wright as she presented on the evening of the 17th of March? 10 A. Correct. That -- what I would say in 11 obstetrics we do, we weigh the risks versus the benefits. 12 The fetus does not -- this is what I teach 13 everybody. The fetus does not get any benefit from lowering 14 maternal blood pressure. When the blood pressure is up in 15 the mother, it's good for the fetus, always. 16 Q. The fetus needs a mother in order to survive? 17 A. Exactly. So we say the mother -- at a certain 18 level, we were worried about them bleeding in their brain. 19 We worry about blood pressure in a certain range to protect 20 the mother, and at the same time make sure uteroplacenta 21 blood flow is adequate. 22 Q. Okay. Did you see Dr. Ashmead's report? 23 A. Yes. 24 Q. We talked about that. Do you agree with 101 1 Dr. Ashmead that hepatic hemorrhage with HELLP syndrome 2 results in maternal death in over half the cases, even with 3 the best of management? 4 A. Yes. That's true. 5 Q. Okay. What is periportal necrosis of the 6 liver? 7 A. Periportal necrosis is injury of liver cells 8 that's around the area where you have the portal 9 circulation. So, really, the portal circulation in the 10 liver is this, where they have the portal vessels. The area 11 around them, you have liver cells. 12 When you have ischemic changes to the liver, 13 the liver cells will then go into necrosis. This is why we 14 call it periportal necrosis. This is why you have elevated 15 liver enzymes, by the way. 16 Q. What is focal necrosis? 17 A. Same thing. Just focal areas of the liver 18 rather than the fields. 19 Q. Did Wanda have either or both of those 20 conditions? 21 A. We don't have autopsy. I can't tell you. 22 These are microscopic things. In the CT scan, you might see 23 these as infarcts, or sometimes you might see them like 24 hemorrhages around this area. 102 1 Q. So if a CT scan had been done, do you have an 2 opinion as to whether it would have shown a periportal or a 3 focal necrosis of the liver? 4 A. I will say most likely not, because, again, 5 based on my experience, if you do them routinely, on HELLP 6 syndrome, most of them would be negative. 7 These are microscopic. It would show up as 8 hemorrhage, intraparenchymal hemorrhage. A CT scan will 9 show you if you have a big infarct. 10 Q. Do you remember what Wanda's readings were? 11 A. Her ALT was 362 and -- let me read them. It's 12 better to be accurate. The ALT was 362 and AST was 678. 13 Q. Is there a correlation between the liver 14 enzyme levels and the actual liver pathology in patients 15 with HELLP syndrome? 16 A. Say that again. 17 Q. Is there a correlation that can be drawn 18 between liver enzyme levels and the actual liver 19 pathology -- 20 MR. HUMPHREY: When you say liver -- 21 BY MR. HIRSHMAN: 22 Q. -- in patients with HELLP syndrome. 23 MR. HUMPHREY: I apologize for interrupting. 24 When you say the "actual liver pathology," what are 103 1 you referring to? 2 A. The biopsy. The answer is no. We actually 3 studied this. And I am one of the persons who studied this. 4 BY MR. HIRSHMAN: 5 Q. So what you're telling me is that, whether the 6 liver enzymes are very high or just moderately high, it 7 doesn't correlate with what you find pathologically when you 8 look at a biopsy? 9 A. Correct. 10 Q. It doesn't correlate with what you find if you 11 look at CT scans, either, of the liver? 12 A. I will say correct. 13 Q. Okay. Is liver involvement in patients with 14 HELLP syndrome considered end organ involvement; in other 15 words, if you have injury to the liver, is that end organ 16 failure? 17 A. It's not failure. The liver is an organ. 18 Q. So when a patient has HELLP syndrome and has 19 the effects on the liver that we've been discussing, that is 20 end organ involvement? 21 A. It's an organ involvement. 22 Q. And -- okay. You've heard the term "end organ" 23 -- 24 A. I know. 104 1 Q. -- "involvement"? 2 A. Yeah. 3 Q. Does liver involvement -- 4 A. Is an organ involvement. 5 Q. Does the liver constitute an end organ within 6 the definition of end organ involvement? 7 A. You see, when people talk about end organ, they 8 are talking about a failure at the end. This is what I'm 9 saying. So, really, the liver is an organ. So, yes, it is 10 involved. It's involved in women of preeclampsia without 11 HELLP. 12 This is what I'm saying. HELLP is a 13 constellation of lab tests. So a woman could have liver 14 involvement. She will not have HELLP. She will have ELLP. 15 This is why when I wrote about the subject I 16 differentiated between woman who have severe preeclampsia 17 and normal liver enzymes and no platelets versus women would 18 have severe preeclampsia and they have either abnormal 19 platelets or abnormal liver enzymes and those who have got 20 everything, the hemolysis and platelets. So, really, HELLP 21 syndrome is severe preeclampsia with more involvement of 22 blood tests. 23 Q. Okay. Would it be fair to describe Wanda's 24 liver enzymes as of 2:50 as being perfectly normal? 105 1 A. Perfectly normal? No, they're not normal. 2 Q. Is there any question about that in your mind? 3 A. No. 4 Q. Okay. Would it be fair to say that to call 5 those enzyme levels perfectly normal would be a gross 6 misstatement of the facts? 7 A. I will say it's not an accurate statement, 8 correct. 9 Q. What does ALT stand for? 10 A. Alanine transferese. And -- I'm trying to 11 remember. They change their terms. We used to call them 12 SGOT. 13 Q. ALT is what used to be called SGOT, correct? 14 A. Yes. 15 Q. Do you know what -- 16 A. AST used to be SGOT. 17 Q. So ALT? 18 A. The A is for alanine, transferase. The other 19 one is -- what is the S? It will come to me in a minute. 20 That's why sometimes it's easier to use the short 21 terminology for it because they have changed the names 22 recently. 23 Q. What is normal -- what constitutes an abnormal 24 ALT? 106 1 A. By my definition -- I introduced criteria. I 2 said, any time you go above 72, this is really abnormal. I 3 use this because this is what is more than double the upper 4 level of normal -- of most in the United States. So I think 5 about 72 is abnormal, 72 or more. 6 Q. How about AST? 7 A. Same thing. 8 Q. About 72? 9 A. Yeah. 10 Q. Is that something that an OB/GYN should know? 11 A. Yes. 12 MR. HIRSHMAN: That's all I have. 13 MR. STACKPOLE: Thank you, Doctor. No 14 questions. 15 MR. HUMPHREY: He'll read. 16 17 ____________________________ BAHA SIBAI, M.D. 18 - - - 19 DEPOSITION CONCLUDED AT 8:53 P.M. 20 - - - 21 22 23 24 107 1 C E R T I F I C A T E 2 STATE OF OHIO : : SS 3 COUNTY OF HAMILTON : 4 I, Brenda J. Duncan, RMR, CRR, the undersigned, a 5 duly qualified and commissioned notary public within and for 6 the State of Ohio, do hereby certify that before the giving 7 of his aforesaid deposition, BAHA SIBAI, M.D. was by me 8 first duly sworn to depose the truth, the whole truth and 9 nothing but the truth; that the foregoing is the deposition 10 given at said time and place by BAHA SIBAI, M.D.; that said 11 deposition was taken in all respects pursuant to 12 stipulations of counsel hereinbefore set forth; that I am 13 neither a relative of nor employee of any of their counsel, 14 and have no interest whatever in the result of the action. 15 IN WITNESS WHEREOF, I hereunto set my hand and 16 official seal of office at Cincinnati, Ohio, this ______ day 17 of _____________________, 2000. 18 19 20 21 ____________________________ My commission expires: Brenda J. Duncan 22 September 21, 2002. Notary Public - State of Ohio 23 24