0001
 1   The State of Ohio,  )
 2   County of Cuyahoga. )  SS:
 3            IN THE COURT OF COMMON PLEAS
 4   Mary Williams, etc., et al.,)
 5            Plaintiffs,        )Case No.
 6            -vs-               )406184
 7   Parma Community General     )
 8   Hospital, et al.,           )
 9            Defendants.        )
10                  - - - o0o - - -
11       Deposition of HELENMARIE WATERS, R.N.,
12   an expert witness herein, called by the
13   Defendants as if upon cross-examination
14   under the statute, and taken before Luanne
15   Stone, a Notary Public within and for the
16   State of Ohio, pursuant to the agreement of
17   counsel, and pursuant to the further
18   stipulations of counsel herein contained, on
19   Saturday, the 2nd day of June, 2001 at 3:00
20   o'clock P.M. at the offices of Weston, Hurd,
21   Fallon, Paisley & Howley, 2500 Terminal
22   Tower Building, the City of Cleveland, the
23   County of Cuyahoga and the State of Ohio.
24   
25   
0002
 1   APPEARANCES:
 2             On behalf of the Plaintiff:
 3             Nurenberg, Plevin, Heller &
 4             McCarthy, by:
 5             Harlan Gordon, Esq.
 6             David M. Paris, Esq.
 7   
 8             On behalf of the Defendant,
 9             Parma Community General
10             Hospital:
11             Weston, Hurd, Fallon, Paisley
12             & Howley, by:
13             John Jeffers, Esq.
14   
15             On behalf of the Defendant,
16             The Women & Wellness Center and
17             William Hahn, M.D.:
18             Bonezzi, Switzer, Murphy &
19             Polito, by:
20             Kevin Kadlec, Esq.
21   
22             On behalf of the Defendant,
23             Physicians Staffing:
24             Hanna, Campbell & Powell, by:
25             Jeffrey E. Schobert, Esq.
0003
 1               P R O C E E D I N G S
 2         HELENMARIE WATERS, R.N., being of
 3   lawful age, having been first duly sworn
 4   according to law, deposes and says as
 5   follows:
 6   CROSS-EXAMINATION OF HELENMARIE WATERS, R.N.
 7   BY MR. JEFFERS:
 8   Q    Please state your full name.
 9   A    It's Helenmarie Waters.
10   Q    And in this case, you offered a report
11   of January 22nd, 2001 on behalf of the
12   Nurenberg, Plevin, Heller & McCarthy law
13   firm, correct?
14   A    Yes.
15   Q    That's your one and only report?
16   A    Yes.
17   Q    And you have no notes that have
18   information that you eventually made this
19   report from.
20   A    No.
21   Q    Did you ever have?
22   A    No.
23   Q    When you went through the chart, did
24   you make notes then?
25   A    No, other than I think here I noted to
0004
 1   go to another page, but that's the only
 2   note.  I -- I usually read my depositions,
 3   and --
 4   Q    What are you looking at now?
 5   A    "Mary Elizabeth Williams, Excerpt Pages
 6   from Record of Parma General Hospital,
 7   6/24/99 to 6/26/99."
 8   Q    That is which was provided by counsel
 9   for the plaintiff, right?
10   A    Yes.
11   Q    You don't have a full chart?
12   A    No.
13   Q    Did you ever have a full chart?
14   A    Yes, I do.
15   Q    Where is that?
16   A    That's at home.
17   Q    Okay.  I take it that you were retained
18   in order to be, and asked to be objective
19   and neutral in your review of this case.
20   A    Yes.
21   Q    Did he specifically use those words, or
22   you just intended to?
23             MR. GORDON:   Objection.  Go ahead
24   and answer.
25             THE WITNESS:   Well, I would have
0005
 1   intended to.  I don't recall exactly the way
 2   it was phrased.
 3   BY MR. JEFFERS:
 4   Q    I'm looking for the first time at your
 5   CV, and you have a copy in front of you,
 6   correct?
 7   A    No.
 8   Q    Oh, I'm sorry.  I see, I thought that
 9   was --
10   A    No, this is mine.
11   Q    I see what you're telling me.
12   A    This is actually just the report, a
13   copy of the report.
14   Q    Okay.  Excuse me for being stupid.
15   A    That's all right.
16   Q    All right.  You are currently director
17   of perinatal services at Prince George's
18   Hospital, Cheverly, Maryland?
19   A    Yes.
20   Q    Okay, but you live in Bowie, right?
21   A    For about a year and a half.
22   Q    Okay.
23   A    Close to two years.
24   Q    And Bowie is where that great race
25   track is, right?
0006
 1   A    Yes.
 2   Q    Okay.  Now, if I look at your CV, I
 3   look back, and I look back, and it seems to
 4   me that you basically had administrative
 5   duties going back to 1987?
 6   A    I've been in an administrative role.
 7   However, as a nurse manager, I've also been
 8   a perinatal clinical nurse specialist during
 9   that time, and I -- my role was the director
10   of women and children's service previously,
11   and a medical service and presently a
12   perinatal service.
13   Q    You overlook the clinical practice of
14   nurses within your institution, correct?
15   A    Yes, I do.
16   Q    And -- and you have responsibility for
17   that, the -- the financial ends of this,
18   correct?
19   A    Yes.
20   Q    You deal with personnel, hiring,
21   firing, whatever?
22   A    Yes, I do.
23   Q    Okay, and you do strategic planning for
24   the obstetric and women's services, right?
25   A    It is part of my job.
0007
 1   Q    You create protocols for standard of
 2   care for practice?
 3   A    Yes.
 4   Q    You do mon -- you implement and monitor
 5   budgeting, right?
 6   A    Yes.
 7   Q    And you coordinate and -- and, then,
 8   there's a line through here, but it looks
 9   like coordinate and process for the
10   department, true?
11   A    The quality management protocol --
12   process.
13   Q    Oh, there's a QI there?
14   A    Yes.
15   Q    Okay.
16   A    I believe that's what that is.  Yes,
17   coordinate QI process.
18   Q    Okay.
19   A    The quality improvement.
20   Q    Okay.
21   A    Regarding clinical practice.
22   Q    Okay.  So, is it not fair to say that a
23   great percentage of your job is
24   administrative in nature?
25             MR. GORDON:   Objection.  Go ahead
0008
 1   and answer.
 2             THE WITNESS:   The administrative
 3   piece that -- that I have coincides and is
 4   ongoing with the clinical practice piece on
 5   my service.  In order to do my job, I spend
 6   a great deal of time with the patients and
 7   with the staff, so it's all entwined.
 8   BY MR. JEFFERS:
 9   Q    Doing what; checking to see whether or
10   not appropriate care is being rendered by
11   your nursing staff?
12   A    In addition to assisting with taking
13   care of the patients and their families.
14             MR. JEFFERS:   Okay.  I'll tell
15   you what.  Would you mark this?
16             (At this time Defendant's Exhibit
17   1 was marked for identification purposes.)
18             MR. JEFFERS:   Thank you.
19   BY MR. JEFFERS:
20   Q    Would not financial -- the financial
21   end be administrative?
22   A    It has -- it has an administrative
23   piece, but it has a -- it has also a
24   clinical piece.
25   Q    Which one?
0009
 1   A    I have to know how to take care of the
 2   patient in order to know what kind of
 3   supplies and what kind of staffing and what
 4   kind of equipment I need to take care of the
 5   patients, and to assure that we have good
 6   outcomes, I have to know those things, so I
 7   have to be out on the service with the
 8   patients and the families.
 9   Q    And finding out what supplies need to
10   be available per patient, right?
11   A    Uh-huh.  It's part of it.
12   Q    Okay.  You -- you -- you look to your
13   nurses who you look -- you supervise to have
14   the hands-on care of these patients, right?
15   A    They have -- they have input, but
16   because I spend a great deal of time in the
17   clinical area, I also make recommendations.
18   Q    When you look at their charting,
19   correct?
20   A    Not just look at their charting, but
21   when I'm taking care of the patient myself,
22   I will look at what is needed and what would
23   be more effective.
24   Q    Are you ever assigned to an individual
25   patient?
0010
 1   A    Yes, I am.
 2   Q    As -- as -- as the nurse in charge of
 3   that patient?
 4   A    Yes.
 5   Q    And how often does that happen?  Not
 6   often, I presume.
 7   A    It happens a number of times a month.
 8   Q    Like what; five or six times you would
 9   have one a month?
10   A    Probably maybe up to eight --
11   Q    Okay.
12   A    -- times a month.
13   Q    That's your hands-on?
14   A    Where it is -- well, no, that's -- you
15   asked me if that's when I was particularly
16   assigned to the patient.
17   Q    Okay, where you are -- where you are
18   the primary assignment, you're the number
19   one nurse for that patient.
20   A    Yes.
21   Q    Okay.  How many days a month are you at
22   the hospital?
23   A    Twenty.
24   Q    Pardon me?
25   A    On an average, 20.
0011
 1   Q    Twenty, thank you.  When you say
 2   personnel management, we discussed that that
 3   was hiring and firing, so that's
 4   administrative, right?
 5   A    That's a piece of it, yes.
 6   Q    When you talk about strategic planning
 7   for the obstetrical and women's service,
 8   that's a -- that's a general overview to
 9   make sure that things are going according to
10   plan, right?
11   A    That and bringing in new patients and
12   increasing our market share, working with
13   physicians, working with the patients we
14   have, doing focus groups.
15   Q    Okay, market share meaning within that
16   -- that medical community --
17   A    Yes.
18   Q    -- in that area of Cheverly, Maryland,
19   right?
20   A    Yes.
21   Q    Okay, and you have strategic -- I'm
22   sorry.  Standards of care protocols, you
23   work on those, right?
24   A    Yes.
25   Q    That's administrative, right?
0012
 1   A    I -- I don't think working on protocols
 2   --
 3   Q    It has nothing to do with patient care.
 4             MR. GORDON:   Wait a minute.  Did
 5   you finish your answer?
 6             THE WITNESS:   I -- I don't -- I
 7   don't know.
 8   BY MR. JEFFERS:
 9   Q    I'm sorry.
10   A    I believe I -- I believe I did.
11             MR. GORDON:   Okay.
12             THE WITNESS:   I was dealing with
13   the question regarding standards.
14             MR. GORDON:   Okay.  Go ahead.
15   BY MR. JEFFERS:
16   Q    Because -- you interpreted it as
17   working -- preparing standards of care
18   protocols because those ultimately affect
19   the care and treatment of the patient,
20   correct; is that -- is that fair or not?
21   A    Yes, but I'm working also with the
22   patients to see that the standard of care
23   that we have established in our service --
24   if there's an administrative piece, there's
25   a clinical piece --
0013
 1   Q    Okay.
 2   A    -- as far as carrying out those
 3   protocols if they are appropriate to the
 4   care of the patients that we serve.
 5   Q    That's to see that your nurses are
 6   carrying them out?
 7   A    Or myself, to see if it's appropriate.
 8   Q    Yeah, but that's only about eight times
 9   a month for you.  You check yourself, in
10   other words, you're saying.
11   A    Well, I spend time with patients.  I
12   may not be the nurse assigned to them, but I
13   spend time with patients, giving them care
14   --
15   Q    Okay.
16   A    -- more frequently than eight times a
17   month.
18   Q    Now, you have drawn in all this
19   bailiwick, implementing and monitoring
20   budgets, correct?
21   A    That's part of my job.
22   Q    Yeah, that is strictly administrative,
23   right?
24   A    Yes.
25   Q    And the -- any process where you're
0014
 1   coordinating or administering, you're
 2   administering, right?
 3   A    I -- I don't understand the question.
 4   Q    Well, you're coordinator, QI process
 5   for department, for the whole -- the whole
 6   obstetrical department, right, or perinatal
 7   department?
 8   A    That's a title, yes, coordinator.
 9   Q    Okay.  So that, with all these things
10   that you do, some of it is extremely
11   time-consuming, I presume, right, like your
12   budgeting?
13   A    At various different times.  It's
14   cyclical.
15   Q    Well, is it fair to say that
16   approximately 70 percent of your time is
17   spent in the realm of administration?
18             MR. GORDON:   Objection.
19             MR. PARIS:     Objection.
20             THE WITNESS:   I would say no,
21   that about 50 percent of my time I have a
22   purely administrative piece, but more --
23   actually 40 percent is mostly
24   administrative, and I would say at least 60
25   to 70 percent has a very strong clinical
0015
 1   component.
 2   BY MR. JEFFERS:
 3   Q    As you define "clinical," right?
 4   A    It has to do with patients and the
 5   daily contact with patients.
 6   Q    Now, what is the classification of
 7   Prince George's Hospital Center?  Is that a
 8   Level 1, 2, 3?  What is it?
 9   A    It's a Level 3 NICU.
10   Q    Pardon me?
11   A    It's a level 3 NICU.
12   Q    Okay.
13   A    And it's a community hospital.
14   Q    What did you review today in
15   preparation for this deposition?
16   A    I wrote that down this morning.
17   Q    You're writing -- you wrote notes you
18   didn't bring, right?  May I see that?
19   A    I didn't consider that a note.  It's
20   just what I reviewed.
21   Q    Okay.  Okay, because when you wrote
22   your report, you didn't -- you hadn't
23   reviewed at that time the depositions --
24   when I say your "note," I mean your report,
25   January 22nd.
0016
 1   A    Yes.
 2   Q    You had not read Hulvalchick or Bazzo,
 3   correct?
 4   A    I had not received those yet.
 5   Q    Okay, and now you've read Martens' and
 6   Crane's, correct, depos?
 7   A    I've read all of those that are there,
 8   yes.
 9   Q    What was -- why would you want to read
10   Dr. Martens' and Dr. Crane's; what does that
11   have to do with nursing?
12   A    Well, I look at, and I believe this is
13   a -- a standard, that doctors and nurses
14   practice taking care of the patient.  We
15   have nursing practice.  We have physician
16   practice, but they are intertwined, and it's
17   a team approach to take care of the patient.
18   Q    Did you read the reports of the various
19   experts that are involved in this case?
20   A    Yes, I did, all of them that I was
21   sent.
22   Q    Okay.  So, is there anything after
23   January 22nd, 2001, when you edited or sent
24   this report out, that you would add to it or
25   subtract from it or make any changes
0017
 1   whatsoever following the review of
 2   additional materials?
 3   A    No.
 4   Q    Okay.  So, that's stand -- that's your
 5   written work.
 6   A    Yes.
 7   Q    Okay, thank you.  Now, since you were
 8   being objective about your review, I want to
 9   ask you about your one, two, three, four,
10   five opinions that are in your report, and
11   you have a copy in front of you, correct?
12   A    Yes, I do.
13   Q    The first opinion that you hold
14   apparently -- and this is the extent of all
15   your opinions for this case, correct, as
16   evidenced in your January 22nd report?
17   A    Yes.
18   Q    All right.  The first opinion is "the
19   nursing staff failed to report the abnormal
20   results of lab work performed on Mrs.
21   Williams to the physicians," correct?
22   A    Yes.
23   Q    How do you -- why do you come to that
24   conclusion when the records themselves show
25   that the nurses reported lab values to the
0018
 1   physicians?
 2             MR. GORDON:   Objection.  Go ahead
 3   and answer.
 4             MR. JEFFERS:   Well, they do show
 5   that, Harley.  It says "lab results."
 6             MR. GORDON:   But you're talking
 7   about abnormal results.
 8             MR. JEFFERS:   I want to know
 9   where she got abnormal from, that they
10   weren't reported.
11   BY MR. JEFFERS:
12   Q    How do you know that?
13   A    Well, the documentation does say "lab
14   results."  It doesn't specifically say
15   abnormal results.
16   Q    All right.
17   A    And a nurse practicing OB would have
18   listed:  the following abnormal results were
19   given to Dr. whoever, and orders received
20   for the following or no orders received, but
21   they would have specifically spelled out
22   what abnormal lab results.
23   Q    You see that in every hospital where
24   you have been on the staff, that these are
25   -- that nurses' notes spell out all -- all
0019
 1   the lab values that are abnormal, every time
 2   --
 3   A    Specifically --
 4   Q    -- they report values?
 5   A    Specifically, if a nurse saw the
 6   abnormal lab results that -- that existed in
 7   this record, she would have listed those
 8   because they were very abnormal, and it was
 9   very -- it was very needed to consult with
10   the physician regarding those lab results.
11   Q    Are you -- are you --
12   A    And to get orders regarding those.
13   Q    You're not an obstetrician, right?
14   A    No, I'm not.
15   Q    You're not a neonatologist, right?
16   A    No, I'm not.
17   Q    You're not a perinatologist; are you?
18   A    No.
19   Q    You're not a doctor, period, correct?
20   A    No.
21   Q    Are you saying that the nurses, for
22   example, should know the meaning of the
23   differentials and be able to come to a
24   conclusion as to what that represents?
25   A    What I said -- what -- I am of the
0020
 1   opinion that a practicing registered nurse
 2   in obstetrics would know that an abnormal
 3   white count and an elevated band would
 4   indicate the potential to have an infection,
 5   and they would have reported, especially the
 6   significant --
 7   Q    Findings?
 8   A    -- findings that occurred.
 9   Q    As opposed to comprehending,
10   necessarily, what the total significance of
11   them are, correct?
12   A    There are nurses that would be able to
13   comprehend that, but they --
14   Q    But you don't expect that.
15             MR. PARIS:     Let her finish,
16   John.
17             THE WITNESS:   The expectation
18   would be that they would know what that
19   indicated.  That is part of our assessment,
20   and we would report those assessment data to
21   the physician for interventions, orders.
22   BY MR. JEFFERS:
23   Q    Okay.  Well, tell me, you read Nurse
24   Prokop's deposition, correct?
25   A    Yes, I did.
0021
 1   Q    And didn't she say she advised doctors
 2   of the lab results?
 3   A    Yes.
 4   Q    But you discount that.  You say she
 5   doesn't in your own mind?
 6   A    If she -- if she did report those
 7   results, and she, according to the chart,
 8   did not receive orders that were -- that
 9   would coincide with interventions necessary
10   for results like that, then, I would have
11   seen notes in the chart related to that
12   these were the abnormal results, and this is
13   Dr. So-and-So contacted; no orders received;
14   and she would have initiated calling the
15   nursing supervisor for support.
16   Q    You think that's the standard of care?
17   A    Yes, I do.
18   Q    In the United States?
19   A    Yes, I do.
20   Q    And even though the nurse might not,
21   and isn't required to appreciate those
22   results and what they might mean in the
23   clinical context, you think she has to take
24   that up with the -- with her supervisor,
25   correct?
0022
 1   A    I did not say that she would not
 2   appreciate what they mean in the clinical
 3   context.  I feel she would know that an
 4   elevated band count and a high white count
 5   that then drops significantly with an
 6   elevated band count, she would know what
 7   that is indicative of.
 8   Q    Any nurse in your service would know
 9   that?
10   A    Yes.
11   Q    At any place you've ever been?
12   A    Yes, and I believe in the testimony --
13   in the depositions, the nurses stated that
14   they did understand what a left shift was
15   and an abnormal white count.
16   Q    But not in terms of the total clinical
17   significance or whether it had any
18   significance, correct?
19   A    I don't recall them saying that.
20   Q    And you wouldn't know either, or at
21   least, somebody -- you wouldn't expect some
22   nurse on your staff to know that.
23   A    I'm not -- I'm not sure of the question.
24   Q    The clinical -- they wouldn't know they
25   were dealing -- what the nature of whatever
0023
 1   -- if they're theorizing it's an infectious
 2   process or that there's a temperature, they
 3   wouldn't necessarily know what the cause of
 4   that temperature was.  You wouldn't expect
 5   them to know that, correct?
 6             MR. PARIS:     You mean the
 7   organism, John, or just the general
 8   infection?
 9   BY MR. JEFFERS:
10   Q    In general.
11   A    Yes, they would know an elevated white
12   count with an elevated temperature and other
13   pieces of assessment data from -- from
14   observing the patient and -- and vital
15   signs, yes, they would know that that was an
16   infection, an infectious process.
17   Q    They would know what the specific
18   infection is?
19   A    You -- I understood you were asking me
20   whether it was an infection or not.
21   Q    No, I'm sorry.  Would they know the
22   specifics of the infection?  Would they know
23   what it really was, what was the infectious
24   process, or what was happening?
25   A    They would know there was an infectious
0024
 1   process.
 2   Q    But not what -- not what type of
 3   infectious process?
 4   A    I'm not sure what you mean by "what
 5   type."
 6   Q    Would they know -- what was it -- what
 7   was it in your understanding this patient
 8   had?
 9   A    She had group A strep.
10   Q    Okay.  Would you expect from the 11:30
11   labs that they would know what -- that they
12   were dealing with a group A staph?
13   A    No, they would not know from the lab
14   results that it was group A strep.
15   Q    Okay.  So, if the nurses say they
16   reported this, you say they didn't because
17   their note didn't elaborate and -- on it for
18   line after line as to what the abnormalities
19   were and what they did and -- and any
20   follow-up on, because the doctor did nothing
21   in response to it, correct?
22   A    And they didn't initiate the chain of
23   command when the doctor did not respond.
24   Q    Okay.
25   A    As they thought.
0025
 1   Q    Well, if a person doesn't know what
 2   type of infectious process they might be
 3   dealing with, and it might be one that is
 4   not an abnormal infectious or -- let me
 5   withdraw that.  You can have lab results in
 6   postpartum women that are abnormal, correct?
 7   A    Yes.
 8   Q    And you might have WBCs that are
 9   outside the normal range of -- that they
10   have at the hospital, correct?
11   A    Yes.
12   Q    Without an infectious process, right?
13   A    That is only -- by -- by -- if you're
14   -- if you're asking me:  are there elevated
15   white counts without having an infection?
16   I'm not sure of the question you're asking
17   me.
18   Q    Without having a -- a -- having a
19   situation where it has any -- any particular
20   significance.
21   A    As a nurse --
22   Q    In a postpartum woman.
23   A    As a nurse, I would look at all of the
24   assessment pieces.
25   Q    Okay.
0026
 1   A    I don't just look at one, small piece
 2   of white count.  I would have looked at all
 3   of the other assessment pieces.
 4   Q    Okay, all right.  "The nursing staff
 5   failed to appropriately assess the patient's
 6   state of restlessness and anxiety and report
 7   these assessment findings accurately to the
 8   patient's physician."  How do you know that?
 9   How do you know they didn't report them
10   accurately?  Where do you get that out of
11   the record?
12   A    When I -- when I see the record, and I
13   see the data that was -- that was available
14   to the staff, such as her lab results, her
15   vital signs, her restlessness, her
16   discomfort, her elevated temp at 7:30, her
17   shaking at close to four o'clock, those
18   things all combined with the restlessness
19   would indicate to me that I needed to
20   contact a physician and tell him that total
21   assessment piece, not just one, small piece
22   of a patient is restless.  Nursing process
23   dictates to us to gather data and make a
24   nursing assessment.  So, I feel that the
25   restlessness needed to be included with all
0027
 1   of the other findings that were there in the
 2   record.
 3   Q    How do you know it wasn't?  Isn't it
 4   reported in there, anxiety, et cetera
 5   reported to the physicians in the chart
 6   itself?
 7   A    Again, if all of this was reported, the
 8   physicians did not respond appropriately,
 9   and the nursing staff did not take the
10   appropriate measures to go then through a
11   chain of command.
12   Q    You, not being a doctor, how do you
13   know that the doctors didn't assimilate the
14   information and decide that nothing had to
15   be done, and, therefore, already made a
16   correct decision?
17   A    With the data that I have, the standard
18   practice that I and other obstetrical nurses
19   would be used to in our clinical setting is
20   that, with those pieces, that there would
21   have been intervention, and antibiotics
22   would have been given.
23   Q    Did you -- have you ever dealt with a
24   staph A case where the -- where later toxins
25   were released and the patient died?
0028
 1             MR. GORDON:   You said "staph."
 2   Okay.  You mean strep, I assume.
 3             MR.JEFFERS:    Strep A, excuse
 4   me.
 5             MR. GORDON:   Why don't you repeat
 6   the question?
 7   BY MR. JEFFERS:
 8   Q    Have you ever dealt with a strep A with
 9   toxins being released with the death of a
10   patient?
11   A    I have -- I have taken care of a
12   patient with Group B -- group A strep
13   infection.
14   Q    Uh-huh.
15   A    And I know of others that were in our
16   institution.  None of them succumbed.
17   Q    Okay.  You don't hold yourself out to
18   say -- to criticize any doctor in this case;
19   do you?
20   A    No.
21   Q    Okay.  Now, the chain of command, have
22   we discussed everything about that?
23             MR. PARIS:     In the context of
24   the question?
25   BY MR. JEFFERS:
0029
 1   Q    In the context of your report.  "The
 2   nursing staff failed to follow the chain of
 3   command if the physicians didn't respond
 4   appropriately once given the assessment
 5   data."
 6   A    Yes.
 7             MR. GORDON:   We're going to ask
 8   her if part of the chain of command includes
 9   asking the doctor to see the patient. Okay.
10             THE WITNESS:   I would have asked
11   -- I would have, during this -- if the
12   physician did not respond appropriately --
13   BY MR. JEFFERS:
14   Q    Okay.
15   A    -- I would have initiated the chain of
16   command, and asked a supervisor to come and
17   review the chart, see the patient, and
18   possibly intervene with the physician for
19   me, and I also would have called the
20   physician and told the physician that there
21   were assessment pieces that I was very
22   concerned about, and I felt that this
23   patient's status was nonreassuring, and I
24   needed that physician to come in and see the
25   patient, yes.
0030
 1   Q    Well, in this case, let's go along that
 2   line.  The nurses called in a qualified
 3   obstetrical physician on two occasions,
 4   right?
 5   A    Yes.
 6   Q    Okay, and besides that, Dr. Hahn and
 7   Dr. Shagawat discussed this patient, right?
 8   A    I believe so.
 9   Q    And the nurses spoke at least five
10   times to Dr. Hahn, correct?
11   A    One, two, three, four -- I believe so.
12   Q    And, so --
13   A    Yes.
14   Q    -- therefore, they did not only contact
15   physicians, but they also had physicians
16   present to examine the patient, correct?
17   A    Yes.
18   Q    And you're saying the nurses in this
19   particular case had no right to rely on the
20   medical judgments of either Dr. Hsieh or Dr.
21   Hahn?
22   A    Dr. Hsieh saw the patient in the
23   hospital.
24   Q    Uh-huh.
25   A    The nurse did not get the response from
0031
 1   Dr. Hsieh or Dr. Hahn that is standard when
 2   you have a patient that has the data that
 3   I've already spoken of, the assessment
 4   pieces, and when discussing this with the
 5   doctor, you would say:  do you -- Doctor,
 6   this is the white count from before.  This
 7   is the white count now.  This is the band
 8   level.  This is a temp of 101.6 at 7:30.
 9   She's now 100.4.  I feel, Doctor, that we
10   need, you know -- do you want us to start
11   antibiotics?  Do you want us to get cultures
12   and start antibiotics?  If that physician
13   responded and did not respond the way I felt
14   necessary and the way our standard practice
15   is in obstetrics, I would then go to my
16   nursing supervisor.
17   Q    Okay.  Now, how many times have you
18   challenged a physician on his orders or his
19   treatment in your life?
20   A    I have discussed with physicians the
21   plan of care with the patient numerous
22   times, too numerous to count.
23   Q    By the way, why do you change your
24   position so often?  You know, you go from
25   one institution to the next.
0032
 1   A    I was at Albany Medical Center for over
 2   14 years.
 3   Q    But then you -- then after --
 4   A    I traveled for a year, and my children
 5   did not do well with me not being home.  I
 6   took a position at a hospital for two years,
 7   and due to personal reasons moved from
 8   Albany, New York to -- to Bowie, Maryland
 9   where we are settled.
10   Q    "The nursing staff failed to identify
11   abnormalities of the patient's blood
12   pressure that required further assessment by
13   a physician."  Are you saying that they
14   never discussed this subject of the
15   patient's blood pressures with any
16   physician?
17   A    I believe at 2:15 in the morning, there
18   was an abnormal blood pressure, and an hour
19   later, there was another abnormal blood
20   pressure, and the nurse -- actually, if I
21   may, I'm going to look into the pages I have
22   from the chart.
23   Q    Uh-huh.
24   A    And at 2:15, the blood pressure was 100
25   on 44, which was significantly different
0033
 1   from the blood pressures that the patient
 2   had previously.  At 3:15 in the morning, her
 3   vital signs were significantly different.
 4   It was now down to 80 on 52.
 5   Q    And how do you know at 3:45 in the
 6   morning the nurse didn't give this
 7   information to Dr. Hahn?
 8   A    And that was -- that is written that
 9   she did contact Dr. Hahn with the status
10   report, I believe.
11   Q    Uh-huh.
12   A    And as Nurse Prokop -- Prokop stated, I
13   believe, in her deposition, that the
14   physician felt that the patient was dry and
15   needed fluid.
16   Q    Uh-huh.
17   A    And this was a significant decrease in
18   blood pressure from this patient who had
19   preeclampsia, a superimposed preeclampsia on
20   her normal condition, and she had had
21   elevated blood pressures above normal, and
22   now was subnormal, and, then, during --
23   during the time from 4:20 -- let me just,
24   from 3:55, the nurse took vital signs, I
25   believe, every five to ten minutes, and the
0034
 1   vital signs continued to be very low right
 2   into 5:00 in the morning.  The nurse should
 3   have called the physician at that time, even
 4   when she called him at 3:30, or --
 5   Q    3:45?
 6   A    3:45, she should have asked the
 7   physician to come in then.  That -- the
 8   blood pressures were significantly low for
 9   this patient.  This is a -- an assessment
10   piece that is way out of norm, and the
11   physician should have come in to see this
12   patient.
13   Q    So, any doctor or expert in this case
14   who would disagree with you as to the
15   significance of these findings in terms of
16   the clinical setting, you would say that
17   doctor doesn't know what he's talking about?
18             MR. GORDON:   Objection,
19   argumentative.  Go ahead.
20             THE WITNESS:   I would say that,
21   based on the assessment that I see as a
22   nurse, an OB nurse, that the patient is
23   restless.  Her blood pressure is
24   significantly low.  She's been febrile in
25   the past.  She's got a significant elevated
0035
 1   bandemia.  She has her white blood cell
 2   count is -- is not normal.  I would have --
 3   I would have said to the physician:  you
 4   need to come in and see this patient.
 5   BY MR. JEFFERS:
 6   Q    Okay, that's what you would do.
 7   A    I --
 8   Q    Right?
 9   A    I -- I would say that that is what a
10   nurse working in OB would do, yes.
11   Q    Now, the next one is interesting to me.
12   It says, "The nursing staff failed to obtain
13   a urine specimen for examination and
14   culture."  Tell me where that's ordered --
15   A    Actually --
16   Q    -- for  --
17   A    In this, the urine specimen for
18   examination is what I meant to say.  They
19   did -- they did do -- it was an order for --
20   Q    C&S?
21   A    -- a C&S.  I believe in Dr. Hahn's
22   deposition, he mentioned that he had ordered
23   a urinalysis also.
24   Q    All right.
25   A    As a nurse, knowing the assessment
0036
 1   pieces that I was giving the physician, I
 2   would know that the culture and sensitivity
 3   specimen would not be back for probably 24
 4   hours, and that if I'm concerned also by
 5   looking at my assessment that this patient
 6   has an infection, if we were looking at the
 7   -- the urine for a site of infection, I
 8   would want to have a urinalysis.  I would
 9   have asked the doctor if we could do a
10   urinalysis, even if he didn't give it to me.
11   A culture is not going to help us for 24
12   hours.
13   Q    Well, you're still going to want to
14   have a culture anyway, right?
15   A    Yes, but --
16   Q    Are you going to treat strictly on --
17   on a urinalysis here?
18   A    The physician's -- the standard of
19   practice that I have seen in OB and that I
20   would say is the standard of practice in
21   obstetrics is that, if a patient has a
22   temperature and other findings that are
23   similar to what this patient's had, we would
24   have started investigating where she is
25   infected.  We would have done blood
0037
 1   cultures, and looked at her pelvis, looked
 2   at her urine, and we would have then treated
 3   her with antibiotics.
 4   Q    And blood culture --
 5   A    A broad spectrum.
 6   Q    Blood cultures take time too, right?
 7   A    Yes, but we would have drawn those
 8   things and --
 9   Q    You say, "we" would have treated with
10   antibiotics --
11             MR. PARIS:     John, let her
12   finish her answer,
13             MR. JEFFERS:   Oh, I'm sorry.
14             THE WITNESS:   We would have --
15   the standard practice that I'm used to in
16   obstetrics is that the patient has symptoms
17   of an infection, has assessment data that
18   goes along with that, that all of the
19   cultures are done.  The patient is then
20   given a broad spectrum antibiotic for an
21   infection, and then is -- then they're
22   treated with the comfort measures and the
23   antipyretics.
24             MR. SCHOBERT:  Move to strike.
25             MR. JEFFERS:   Yeah.
0038
 1             MR. SCHOBERT:  She's not qualified
 2   to give that answer.
 3             MR. JEFFERS:   Correct.
 4   BY MR. JEFFERS:
 5   Q    That's what you see done.  You
 6   obviously cannot prescribe an antibiotic for
 7   any patient on this earth, right?
 8   A    As I said, it's the standard practice
 9   that I have practiced in that environment.
10   Q    But you don't order it, right?
11   A    No.
12   Q    You have -- you have no right to order
13   it, correct?
14   A    No.
15             MR. PARIS:     She testified
16   that's her experience, what she's observed.
17             THE WITNESS:   Yes.
18             MR. JEFFERS:   It doesn't matter
19   what she's observed.  This is a very unusual
20   situation here.  So, how does she know what
21   -- she's not -- she's not able to give a
22   medical opinion, and you know that.
23             MR. PARIS:     That's your
24   opinion.
25             MR. JEFFERS:   That is -- that is
0039
 1   the opinion of the courts of this state.
 2   BY MR. JEFFERS:
 3   Q    Now, did you notice that the order was
 4   countersigned for the C&S?
 5             MR. GORDON:   Why don't you look
 6   at the order.
 7             THE WITNESS:   Yes, it was
 8   countersigned.
 9   BY MR. JEFFERS:
10   Q    And it doesn't mention urinalysis; does
11   it?
12   A    I believe it's countersigned for the
13   orders that are there.
14   Q    Right.  It doesn't mention urinalysis,
15   is my question.
16   A    On -- on the order that is
17   countersigned for C&S, it does not mention
18   urinalysis on that line.
19   Q    And a countersignature means that they
20   agree with the order that they had given
21   over the phone, or however it may have been
22   given, correct?  Normally, that's what it
23   means?
24   A    Normally, the signature is that they
25   did give that order.
0040
 1   Q    Okay, but you're saying you don't think
 2   that was the order given, right?
 3   A    I believe there's another order that
 4   was given or should have been given.
 5   Q    Well, those are two different things.
 6   A    (At this time the witness shrugged her
 7   shoulders.)
 8   Q    You're saying that Nurse Bazzo, even
 9   though she has a clearly written order that
10   is countersigned, that that's not the order
11   she received; is that your opinion?
12   A    My opinion is that there --
13   Q    No, is that your opinion, the way --
14             MR. GORDON:   Let her explain.
15   Let her explain her opinion.
16   BY MR. JEFFERS:
17   Q    No.  I'm asking.  That's a yes or no,
18   and then you can give an explanation.
19   A    Yes, I feel that there's an order for
20   a urinalysis that's missing.
21   Q    Even though there's a countersignature
22   on it?
23   A    Yes.
24   Q    And even though you understand that a
25   countersignature normally means that:  I
0041
 1   agree with the order, correct?
 2   A    The countersignature is -- means that
 3   they gave those -- that order, and they're
 4   signing for that order that's written.
 5   Q    Okay.  Did you expect that there would
 6   be two separate orders, one for a urinalysis
 7   and one for a C&S given, if that's what the
 8   total order was, that they would write them
 9   separately, or would you expect to see it
10   all in one order?
11   A    I've seen it both.
12   Q    Why in god's name would you have put a
13   urinalysis in a separate -- on a one-line
14   order or two-line order; why would you put a
15   urinalysis separate from the C&S?  Why?
16             MR. PARIS:     Objection.
17   BY MR. JEFFERS:
18   Q    Give me a reason for it.
19             MR. PARIS:     You want her to get
20   into the head of the author of that?  What
21   do you want her to do, get into the mind of
22   the author?
23             MR. JEFFERS:   Wait.  How many of
24   you guys are representing her?  I'm not
25   going to take it from both of you.
0042
 1             MR. PARIS:     The entire
 2   Nurenberg law firm is representing her.
 3             MR. JEFFERS:   Not for this
 4   deposition.  One can object.  I'm not taking
 5   it from two.
 6             MR. PARIS:     Well, we're both
 7   here, so we're both vocal.
 8             MR. JEFFERS:   Well --
 9             THE WITNESS:   I would --
10   BY MR. JEFFERS:
11   Q    What is the normal way to write that
12   order?  You write urine -- urinalysis and
13   C&S, right?
14   A    That's one way.  I have seen --
15   Q    That's the normal way?
16   A    I have seen, if -- if -- if a physician
17   said to me:  get a urinalysis, and then get
18   a culture and sensitivity, I would have
19   written two different things.
20   Q    Well, if you're -- if you're getting it
21   on a telephone call --
22   A    Yes.
23   Q    -- and you're getting it one time, and
24   then you're writing down the orders, isn't
25   that how you'd write it?
0043
 1   A    I've seen it both ways.  That's my
 2   answer.
 3   Q    The normal, majority way is you write
 4   them both; wouldn't you?
 5             MR. PARIS:     She's answered the
 6   question, John.
 7             MR. JEFFERS:   No, she hasn't.
 8             MR. PARIS:     Yes, she has.
 9             MR. JEFFERS:   I want to know that
10   answer.
11             MR. PARIS:     The normal,
12   majority way?
13             MR. JEFFERS:   Yeah.
14             MR. PARIS:     Can you define --
15             MR. JEFFERS:   Listen, I'm not
16   going to argue with you.  Who -- who's here?
17   BY MR. JEFFERS:
18   Q    Are you going to answer me?
19   A    Could you please -- would you please
20   repeat what it is, the question that you're
21   asking me at this moment?
22   Q    Are you looking at the order now?
23   A    Yes, I am.
24   Q    And what page is it on?
25   A    It's on page 179.
0044
 1   Q    Okay, and --
 2   A    The middle of the page.
 3   Q    Obtain urine -- urine sample for
 4   catheter, right?
 5   A    From catheter.
 6   Q    From catheter for C&S, right?
 7   A    Yes.
 8   Q    Now, if you're going to get that urine
 9   sample, aren't you going to use that for two
10   things, for the C&S and for the urinalysis?
11   A    You may, yes, yes.
12   Q    Yes?
13   A    Yes, from a catheter, yes, you would.
14   Q    Okay.  So, if you're writing it, you,
15   as a nurse, if you were going to write that,
16   and you just had a telephone call, wouldn't
17   you write that together if that were true?
18   A    Yes.
19   Q    Okay.
20   A    I would.
21   Q    Because that's the appropriate way to
22   write it?
23   A    It's a way to write it.
24   Q    Okay.  By the way, I notice there's no
25   address on your report of January 22nd.  Why
0045
 1   is -- why is that?  All it says is your name
 2   on the bottom.  Where are you working when
 3   you typed this up?
 4   A    I'm sorry?
 5   Q    Where were you when you typed this up?
 6   There's no address.  I don't know where --
 7   in other words, you've got a letter, and it
 8   doesn't show where -- who -- you know, it
 9   shows your name, but it doesn't say where
10   your address is, which is a normal form of
11   writing a letter, and all I want to know --
12             MR. GORDON:   Objection.
13             MR. PARIS:     Objection.  It's
14   normal for who, John?
15   BY MR. JEFFERS:
16   Q    Why is there no address on this?
17   A    Because I wouldn't have thought to put
18   my address on it.
19   Q    You never do on any of your reports?
20   A    No.
21   Q    Do you --
22   A    Because I was sending -- I was sending
23   my comments to Mr. Paris.  He -- if he
24   needed to know where I lived, he would know
25   that because he sent me the depositions.
0046
 1   Q    Do you have -- do you have a business
 2   address for writing -- for doing legal
 3   research?
 4   A    No, no.
 5   Q    And work and reporting?
 6   A    No.
 7   Q    Where do you do it, at the hospital or
 8   at home?
 9   A    I do it at home.
10   Q    Do you do any of them ever at the
11   hospital?
12             MR. GORDON:   Objection.
13             THE WITNESS:   No.
14   BY MR. JEFFERS:
15   Q    Do you review them at the hospital?
16   A    No.
17   Q    Okay.  Prior to writing this report,
18   did you discuss it with counsel from
19   Nurenberg, Plevin?
20   A    No, I wrote the report after I read the
21   depositions and looked at the chart.
22   Q    Okay.  I want to go back in your CV,
23   and I'd like to know:  when was it that you
24   basically were a clinical staff nurse as a
25   full-time profession?
0047
 1   A    I -- I'm not sure what you mean by a
 2   "clinical staff nurse."
 3   Q    Okay.  When did you act, as opposed to
 4   having administrative duties, other than
 5   that of a floor nurse, when -- when were you
 6   -- when were you a floor nurse without
 7   having all these administrative adjuncts?
 8   A    Well, during my career, because of the
 9   -- the business of obstetrics, I have always
10   had to take care of patients because our
11   census is so fluctuating.  I've always had
12   -- I -- I'm clinically competent to take
13   care of labor and delivery patients and
14   postpartum and nursery patients.
15   Q    All I want to know is:  did you ever
16   just act like -- like a Prokop or a Bazzo?
17   A    Yes, yes, I did.  Yes, I did.
18   Q    When was that?
19   A    Two -- up until -- it was -- it was in
20   -- in the '80's.
21   Q    Uh-huh.
22   A    And I believe you mean swipe in as a
23   staff nurse and swipe out as a staff nurse.
24             MR. PARIS:     Is that what you
25   mean, John?
0048
 1             THE WITNESS:   Is that what you
 2   mean?
 3   BY MR. JEFFERS:
 4   Q    I'm sorry.  What was the question?
 5   A    Is that what you mean, that I came --
 6   came to work; I swiped in; and I was a staff
 7   nurse?
 8   Q    Yes, right.
 9   A    Okay.
10   Q    Now, you go around lecturing also,
11   right?
12   A    I lecture.
13   Q    How many times?  It looks like you go
14   everywhere, lecturing all over the country
15   perhaps.
16   A    No.
17             MR. GORDON:   Objection.  Go ahead
18   and answer.
19             THE WITNESS:   No.
20   BY MR. JEFFERS:
21   Q    Pardon me?
22   A    Usually just regionally.
23   Q    Oh, regionally?
24   A    Yes.
25   Q    How much time do you spend lecturing?
0049
 1   A    Nowadays, just to my own staff.
 2   Q    Just when?
 3   A    In the last two years, just to my own
 4   staff.
 5   Q    Okay.
 6   A    When you call it lecturing, I call it
 7   teaching, actually.
 8   Q    I used the word because it says
 9   "numerous lectures."
10   A    Right.
11   Q    Do you still do any research?
12   A    At the present time, I'm -- I'm
13   involved in a research project.
14   Q    And is it for a company --
15   A    No.
16   Q    -- versus the hospital?
17   A    No.  It's at the hospital.
18   Q    What is the -- what is the research
19   process -- program that you're in?
20   A    At the present time, we're looking at
21   deliveries under 20 -- under 24 weeks and
22   over 20 weeks.
23   Q    And -- and tell me about the group
24   that's doing this.  Who's involved?  Are you
25   a statistician, or are you actively doing
0050
 1   something else?
 2   A    I'm actively -- I'm gathering the data
 3   and working with -- taking care of the
 4   patients, interviewing the patients and --
 5   and, you know, working with the charts and
 6   the -- and the -- and the assessment data on
 7   the patients.
 8   Q    That's -- that's ongoing right now?
 9   A    Yes, it is.
10   Q    I had -- I had a sheet of paper here
11   with a note on it.  Thank you.
12   A    And I'm working on that with some of
13   the nurses in obstetrics, some of the nurses
14   in the neonatal unit.
15   Q    You're not claiming that the 2020 entry
16   on June 25th is a deviation from the
17   standard of care, right; in other words,
18   your comment about "the nursing staff failed
19   to obtain a urine specimen for examination
20   and culture"?
21   A    As I said, the "and culture," that was
22   a mistake.  The culture is -- is here.  It's
23   the urinalysis for examination.
24   Q    Is that --
25   A    That I felt should have been -- should
0051
 1   have been asked for and obtained.
 2   Q    Okay.  So, you're saying that's a
 3   deviation?
 4   A    Yes.
 5   Q    Okay.  So, it would go back a little
 6   further than your note on deviations.  Any
 7   other deviations before 2020?
 8   A    On -- yes.  The --
 9   Q    Okay, so much for this note.
10   A    Well, I think it goes with the -- the
11   -- the assessment data and -- and following
12   the chain of command, looking at the
13   temperature at 7:30 of 101.6.  I believe at
14   eight -- I think it was 8:30, they did
15   discuss with Dr. Hahn.  That's in the chart.
16   So, they did talk to Dr. Hahn during that
17   time, and at that time, they should have
18   reported the elevated temperature and the
19   lab data from previously that was abnormal,
20   and then, again, in following the chain of
21   command, if they didn't receive, you know,
22   the appropriate follow-up.
23   Q    What time was the first deviation from
24   the standard of care that you found?
25   A    Well, I would say that it -- it's at
0052
 1   7:30.
 2   Q    And you've already explained that.
 3   A    Yes.  In addition, the -- along with
 4   the -- the piece about appropriate -- the
 5   second bullet, "appropriately assess the
 6   patient's state of restlessness and anxiety
 7   and report these assessment findings,"
 8   meaning to report and pull all of that in
 9   addition to other pieces of assessment, such
10   as the temperature.  I know that they had
11   taken the temperature at 7:30.  The next
12   temperature was not taken until, I believe,
13   12:30, and that was five hours, which is not
14   according to their protocol.  The protocol,
15   I believe, that I saw on mag -- actually, I
16   have it stated that -- that vital signs --
17   that temperatures should be every four
18   hours, and that if it was abnormal, it
19   should be every two.  So, 101.6 was
20   abnormal, and it should have been done
21   again at -- at 9:30.
22   Q    And you say at the conclusion, "I have
23   the opinion that these deviations in the
24   standard of practice contributed to the
25   outcome of this patient."  Isn't that within
0053
 1   the realm of an M.D. or a D.O.'s conclusion
 2   and not yours?
 3   A    I -- what I meant by that statement is
 4   that, the nurses deviated from the standard
 5   of practice of nurses, and that by not
 6   notifying the physician and not implementing
 7   the standard of -- the chain of command,
 8   that it contributed to the -- the possible
 9   nonintervention in a timely manner.  That's
10   what I meant, not in a timely manner, the
11   physician coming in to see the patient or
12   ordering the appropriate things for
13   infection.
14   Q    But medically speaking -- I mean,
15   speaking from a nursing standpoint, you
16   can't opine as to whether or not if -- if
17   there were violations of any of these
18   standards, that in the end, it had any -- it
19   made any difference in the outcome of this
20   case, correct?
21   A    No, I can't.
22   Q    Okay.
23   A    From a nursing standpoint.
24   Q    Now, how much time do you spend on this
25   -- what you -- what I read as lecture, but
0054
 1   it comes under teaching.  That's teaching
 2   that's done in-service, correct?
 3   A    Yes.
 4   Q    Okay.
 5   A    Or there's a lot of teaching that I do
 6   with -- at the moment we have a lot of new
 7   people that have just recently started, and
 8   I've been working with them on fetal
 9   monitoring reviews and newborn assessments.
10   Q    What do you say in a given year your
11   percentages are on that form of teaching or
12   lecture?
13   A    I probably do it formally probably once
14   a month, but informally, I do it probably
15   every day for about an hour.
16   Q    On the formal ones, about once a month?
17   A    Formal, about once a month, an hour.
18   Q    Okay.  How much time do you spend every
19   month on establishing standards of care
20   protocols?
21   A    An hour.
22   Q    One hour a month?
23   A    Uh-huh.
24   Q    How about budget work?
25   A    Two hours.
0055
 1   Q    These are all by the month?
 2   A    Uh-huh.
 3   Q    How about personnel management?
 4   A    That -- that -- that varies; probably
 5   three hours a month, four hours a month.
 6   Q    How about strategic planning?
 7   A    That's one hour a month.
 8   Q    Did I do the financial?
 9   A    You did budget.
10   Q    Number of hours?
11             MR. PARIS:     Two hours per
12   month?
13             THE WITNESS:   Yeah, two hours.
14   BY MR. JEFFERS:
15   Q    Okay, you're calling that the budget
16   too.  Okay, that's not a separate one.  It's
17   listed separately.  You say financial and
18   personnel matters.
19   A    But once a year, I do more of an
20   intensive, you know, getting ready to do
21   year -- yearly budget.  That's a different
22   issue.
23   Q    Okay, and how much -- how many hours a
24   month on -- well, per annum?
25   A    Yeah, that's -- that's on an annual
0056
 1   basis.
 2   Q    How much is that?
 3   A    Like 16 hours annually.
 4   Q    Now, you indicated that eight times a
 5   month, you would have a primary assignment
 6   at the hospital?
 7   A    Yes.
 8   Q    And would that mean that you would be
 9   an entire shift?
10   A    It varies.
11   Q    What is -- tell me how it varies.
12   A    Anywhere from four to 12 hours.
13   Q    Why does it -- why does it -- why is
14   there a four-hour, or was that standard for
15   your nurses?  Some of them only have a
16   four-hour shift?
17   A    Uh-huh.
18   Q    Let's say in a given day, I take it you
19   have an office.
20   A    Uh-huh.
21   Q    What percentage of time do you spend
22   not just in the office but wherever else you
23   might be, in an administrative office or in
24   a meeting; how much time per day would you
25   average out off the floor of the patient
0057
 1   floor -- off a patient floor?
 2   A    I would say it's probably four hours on
 3   the floor and probably, on an average, three
 4   hours in my office and one hour of meetings,
 5   if you averaged it all out.
 6   Q    Plus the time -- plus there's the time
 7   which you do at home to review cases, right?
 8   A    That's not very often.
 9   Q    Huh?
10   A    It's not very often.
11   Q    How many cases have you had in your
12   life and from when?
13             MR. GORDON:   Medical malpractice
14   cases; is that right?
15   BY MR. JEFFERS:
16   Q    Medical malpractice.
17   A    Probably 13 in -- probably 13 in 13.
18   Q    Thirteen in 13 years?
19   A    Yeah.
20   Q    All right, and how did -- do you know
21   how you came to be contacted by Mr. Paris or
22   by anybody else at that office?
23   A    I have -- I believe it was through
24   another -- a physician that I know who does
25   --
0058
 1   Q    Reviews?
 2   A    Yeah.
 3   Q    Who's that?
 4   A    It's possible that it -- it may be one
 5   of the docs I worked with in Albany.  His
 6   name is Vincquerra.
 7   Q    Is he involved in this case?
 8   A    Oh, no, no, but he does work through --
 9   he does a significant number of cases, and I
10   know he's -- he has referred people to me.
11   Q    Are you saying he does significant
12   cases through an agency?
13   A    No.
14   Q    Where -- you were going to say through
15   or what, and then you stopped.
16   A    He -- he has an association with Albany
17   Law, so I know that he has done --
18   Q    What is Albany Law?
19   A    Albany Law School.
20   Q    Pardon me?
21   A    Albany Law School.
22   Q    Okay, and what's his association with
23   that have to do with how he gets cases?
24   A    I  -- I just know that he -- I really
25   don't know.  I just know that he has
0059
 1   referred a couple of people to me.
 2   Q    Do you --
 3   A    Or to -- me to a couple of people.
 4   Q    How many plaintiffs' cases were the 13
 5   and how many defense?
 6   A    Eight and five.
 7   Q    Eight Ps?
 8   A    Yes.
 9   Q    And five defense?
10   A    Yes.
11   Q    Have you ever done a case in Ohio
12   before?
13   A    I don't believe so.
14             MR. GORDON:   Yeah, we --
15             THE WITNESS:   Oh, yes, with --
16   once with Mr. Jacobson.  I'm sorry.
17   BY MR. JEFFERS:
18   Q    One other?
19   A    Yes.
20   Q    And is that case pending?
21   A    No.  That settled.
22   Q    What was that case about?
23   A    I don't recall, honestly.
24   Q    How long ago was that?
25   A    I think it was like two years ago.
0060
 1   Q    You have no idea what it revolved
 2   around?
 3   A    To be perfectly -- I'm being truthful.
 4   I don't remember.
 5   Q    Did it have anything to do with any
 6   infections?
 7   A    No, that I know of.
 8   Q    But it could?
 9             MR. PARIS:     She just said she
10   doesn't remember, John.
11             MR. JEFFERS:   And then she said
12   it could.
13             THE WITNESS:   I don't remember.
14   BY MR. JEFFERS:
15   Q    Okay.  Did you give any deposition in
16   that case?
17   A    I believe I just did trial.
18   Q    No deposition?
19   A    I -- I --
20   Q    Like this?
21   A    I don't -- I don't recall.
22   Q    You went to trial?
23   A    I recall -- I recall the trial.  I do
24   not recall the deposition.
25   Q    You testified at trial.  Do you know
0061
 1   the case?
 2   A    No.
 3   Q    Do you know the opposing attorney?
 4   A    No.
 5   Q    It was settled before the jury rendered
 6   a verdict; is that what you're telling me?
 7   A    I don't -- I don't recall.
 8   Q    And that would be the only time you've
 9   testified one way or the other in the state
10   of Ohio, other than today?
11   A    Yes.
12   Q    Okay.  When you were previously at
13   Glens Falls, was your job similar to the one
14   you now have?
15   A    Yes.
16   Q    At Marquette, it was a little
17   different, I take it, right?
18   A    Yes, it was, and at Glens Falls, it was
19   strictly --
20   Q    Pardon me?
21   A    At Glens Falls Hospital, it was
22   strictly a community hospital.
23   Q    Okay.  At your hospital, do you have
24   high risk kids?
25   A    Yes, we do.
0062
 1   Q    Okay.  At -- although part-time at
 2   Albany, that was a similar position?
 3   A    Albany Memorial?
 4   Q    Uh-huh.
 5   A    That was a part-time job I had for five
 6   years.  I worked every other weekend as a
 7   nursing supervisor in a community hospital.
 8   Q    Okay, it says "position has
 9   administrative responsibilities on a
10   part-time basis --"
11   A    Yes.
12   Q    "-- for coordination."
13   A    I did -- I -- I was at Albany Medical
14   Center as a clinical nurse specialist during
15   that time, if you notice the dates.
16   Q    Uh-huh.
17   A    I had two jobs.
18             MR.JEFFERS:    That's it.  Do you
19   have any questions?
20             MR. SCHOBERT:  Yeah, I do have a
21   couple.
22   CROSS-EXAMINATION OF HELENMARIE WATERS, R.N.
23   BY MR. SCHOBERT:
24   Q    I just want to make sure of a couple
25   things.  You are not a physician, correct?
0063
 1   A    No.
 2   Q    Not gone to medical school?
 3   A    No.
 4   Q    Not gone into any residency or training
 5   in OB/GYN; is that correct?
 6   A    No.
 7   Q    In your hospital, there are physicians
 8   that render care to patients in the
 9   perinatology department, correct?
10   A    Yes.
11   Q    And there are nurses that assist in the
12   management of the patients; is that correct?
13   A    Yes.
14   Q    And you used the term on a number of
15   occasions, normal standard of practice or
16   normal standard practice.  Is that -- am I
17   to infer that that is the normal standard of
18   practice for what you believe to be nursing
19   care?
20   A    The -- the care of the patient.  When I
21   -- when I mean at -- when you work, you
22   can't -- I mean, nursing and medicine don't
23   practice in two separate worlds.  We're in
24   the -- it's the same patient.  Physicians
25   write orders, plan care.  The nurse is part
0064
 1   of that team of planning the care.  The
 2   nurses have nursing care and, then, assist
 3   in the carrying-out of physicians' plan of
 4   care.
 5   Q    But if I'm clear, the doctors have
 6   different training, different background and
 7   different duties to the patient; is that
 8   correct?
 9   A    Yes.
10   Q    Different expectations as to what they
11   will do in terms of the care they render; is
12   that correct?
13   A    Yes.
14   Q    And they -- it would be fair to state
15   they have more extensive care and training
16   than you do in your nursing background?
17   A    For medicine, yes.
18   Q    Okay, and, so, when we talk about the
19   normal standard practice, there are
20   components of that, that are strictly those
21   that physicians provide and make decisions
22   concerning; is that correct?
23   A    And I would be, as a nurse or other
24   nurses in OB would be -- have -- have a
25   knowledge of that, because we're -- we're
0065
 1   the ones that are carrying out that
 2   physician's standard of practice.
 3   Q    So, you have the same degree of
 4   knowledge that the doctors do concerning the
 5   decisions they make?
 6   A    It's not -- that's not what I said.
 7   Q    Well, but are you writing the orders,
 8   making the -- the decisions on what orders
 9   need to be written for a given patient?
10   A    I don't write orders independently of
11   the physician.
12   Q    Do you make the final determinations as
13   to diagnosis and the appropriate treatment
14   that a patient needs to be rendered in a
15   given situation?
16   A    No, not the final diagnosis.
17   Q    So, would you agree with me there is a
18   difference in the degree of skill and
19   expertise that you have as a nurse than that
20   of the physicians that you work with?
21   A    For?
22   Q    For the care rendered to patients in a
23   perinatology ward.
24   A    You're talking about medical care
25   versus nursing care?
0066
 1   Q    Well, I'm trying to distinguish.  I
 2   can't quite come to a decision what you
 3   distinguish the difference to be between
 4   nursing and medical care, and that's all I'm
 5   trying to ask you about.  Is there a
 6   difference between the two?
 7   A    Yes, there is.  Nursing -- nursing has
 8   -- has a certain education that goes with
 9   nursing.  Medicine has their education.
10   There are pieces, though, that are taught to
11   nurses that assist us and -- so that we are
12   the ones that are 24 hours a day with that
13   patient, we will gather that data and report
14   it to the physician.  We have to have a
15   knowledge base and know what we're looking
16   for, and what to report to a physician, or
17   the physicians would need to be in the house
18   24 hours a day, seven days a week.  Nurses
19   have data that they gather.  They make an
20   assessment as to whether this is normal data
21   or abnormal data, and they report it, and
22   know that the physician must respond for
23   pieces, such as a temp of 105 would need a
24   physician to assess that patient because
25   that is abnormal data.
0067
 1   Q    Why do you -- excuse me.  I'm sorry.  I
 2   didn't mean to interrupt.
 3   A    And I would know, as a nurse and
 4   through my training, that that is -- that
 5   particular piece of data is something that a
 6   physician needs to -- to know and needs to
 7   intervene on.
 8   Q    All right.  Is -- is there any real
 9   reason then to have a physician involved in
10   the process?  If you as a nurse know what
11   needs to be reported and know what needs to
12   be done, what's then really the role of the
13   physician?
14   A    There are pieces that go above -- the
15   physicians do have an education that is
16   different from nursing, but I have to know
17   the pieces of data that he -- he or she
18   wants me to report to them to take adequate
19   care of their patient.  It is a team
20   approach.  The physicians will take the data
21   I give them and will make decisions.
22   Whether they're right or wrong, they take
23   those -- that information and make
24   decisions.
25             MR. SCHOBERT:  All right.  I have
0068
 1   no further questions.
 2             MR. JEFFERS:   You?
 3             MR. KADLEC:     No.
 4             MR. JEFFERS:   Pardon me?
 5             MR. KADLEC:    No, no questions.
 6             MR. JEFFERS:   I have another
 7   question.
 8              RECROSS-EXAMINATION OF
 9             HELENMARIE WATERS, R.N.
10   BY MR. JEFFERS:
11   Q    You don't have any writings or
12   publications that you participated in,
13   right?
14   A    No.
15   Q    So, I can't find any book where you set
16   standards for nurses in there or anything or
17   any publication of that sort, right?
18   A    The only -- it was -- it was kind of
19   funny.  The only thing, I do use the book
20   that the hospital uses, that core curriculum
21   for maternal newborn nursing.
22   Q    Uh-huh.
23   A    I do use that just as a -- as a
24   reference guideline for some of our
25   orientation program to our postpartum.
0069
 1   Q    Well, now, you haven't -- you haven't
 2   edited, done anything in writing or even
 3   suggested in writing what the standards for
 4   nursing are under any particular situation,
 5   right?
 6   A    No.
 7   Q    Okay.
 8   A    I haven't published, if that's what
 9   you're asking.  Is that what you're asking?
10   Q    Yes.  Thank you.
11             MR. GORDON:   She'll read.
12   
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0070
 1                    CERTIFICATE
 2   The State of Ohio,   )
 3   County of Cuyahoga.  )   SS:
 4       I, Luanne Stone, a Notary Public within
 5   and for the State of Ohio, duly commissioned
 6   and qualified, do hereby certify that the
 7   within-named witness, HELENMARIE WATERS,
 8   R.N., was by me first duly sworn to testify
 9   to the truth, the whole truth and nothing
10   but the truth in the case aforesaid; that
11   the testimony then given by the
12   above-referenced witness was by me reduced
13   to stenotypy in the presence of said
14   witness; afterwards transcribed; and that
15   the foregoing is a true and correct
16   transcription of the testimony so given by
17   the above-referenced witness.
18       I do further certify that this
19   deposition was taken at the time and place
20   in the foregoing caption specified and was
21   completed without adjournment.
22       I do further certify that I am not a
23   relative, counsel or attorney for either
24   party, or otherwise interested in the
25   event of this action.
0071
 1       IN WITNESS WHEREOF, I have hereunto set
 2   my hand and affixed my seal of office at
 3   Cleveland, Ohio this ______ day of
 4   _______________, A.D., 2001.
 5   
 6   
 7                 ____________________________
 8                 Luanne Stone, f.k.a. Protz
 9                 Notary Public
10                 In and for the State of Ohio
11                 My commission expires 4/6/03
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