0001 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 4 5 SHANNON SULLIVAN, et al., 6 7 PLAINTIFF(s), 8 V. 9 CASE NO. CV-09-697617 10 11 THE CLEVELAND CLINIC FOUNDATION, 12 13 DEFENDANT. 14 ______________________________________________ 15 16 TELEPHONIC DEPOSITION FOR THE PLAINTIFF(s), 17 SHANNON SULLIVAN, et al.: 18 19 The Telephonic Deposition of Alex Abou-Chebel, 20 M.D., taken in the above-styled matter at the 21 University of Louisville School of Medicine, Department 22 of Neurology, 500 South Preston Street, Room 114, 23 Louisville, Kentucky, on the 7th day of April, 2010, 24 beginning at 9:40 a.m. 25 0002 1 A P P E A R A N C E S 2 3 FOR THE PLAINTIFF(s), SHANNON SULLIVAN, et al.: 4 DAVID A. KULWICKI, ESQUIRE 5 BECKER & MISHKIND CO., LPA 6 1660 West Second Street 7 660 Skylight Office Tower 8 CLEVELAND, OHIO 44113 9 [VIA TELEPHONE] 10 11 FOR THE DEFENDANT, THE CLEVELAND CLINIC 12 FOUNDATION: 13 ANNA MOORE CARULAS, ESQUIRE 14 ROETZEL & ANDRESS 15 1375 East Ninth Street 16 One Cleveland Center 17 CLEVELAND, OHIO 44114 18 19 20 21 22 23 24 25 0003 1 INDEX TO EXAMINATION 2 3 PAGE 4 EXAMINATION BY MR. KULWICKI . . . . . . . 4 5 6 7 8 INDEX TO EXHIBITS 9 10 PAGE 11 EXHIBIT A . . . . . . . . . . . . . . . . . . . . . . . 4 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0004 1 TELEPHONIC DEPOSITION OF 2 ALEX ABOU-CHEBL, M.D. 3 APRIL 7, 2010 4 ALEX ABOU-CHEBL, M.D., called on behalf of the 5 Plaintiff(s), Shannon Sullivan, et al., after having 6 first been duly sworn, is examined and testifies as 7 follows: 8 EXAMINATION 9 BY MR. KULWICKI: 10 Q. Doctor, would you kindly state your -- 11 your full name and spell your last name. 12 A. Alex Abou-Chebl, M.D., A-b-o-u, hyphen, 13 C-h-e-b-l. 14 Q. And, Doctor, would you give us your 15 current business address? 16 A. Department of Neurology, Room 114, 17 University of Louisville School of Medicine, 500 18 South Preston Street, Louisville, Kentucky 40202. 19 Q. Doctor, did you bring a copy of your CV 20 with you today? 21 A. Yes. 22 Q. We'll mark that as Exhibit 1. 23 [WHEREUPON, document referred to is marked 24 Exhibit 1 for identification.] 25 BY MR. KULWICKI: 0005 1 Q. Since I don't have it in front of me, let me 2 just ask you a few questions. Can you run through 3 your education and -- 4 MS. CARULAS: Just a minute. Dave, 5 just a minute, because she was marking it for you. 6 Okay. Wait -- just wait one second. We'll tell you 7 when she's ready. 8 MR. KULWICKI: Thank you. 9 THE REPORTER: Okay. Go ahead. 10 A. Okay. Ask your question again, please. 11 BY MR. KULWICKI: 12 Q. Sure. Can you just briefly run through 13 your education and training starting with medical 14 school? 15 A. Attended medical school 1991 through 16 1995 at Case Western Reserve University. I 17 performed an internship in preliminary at St. 18 Mary's Medical Center and Hospital at San 19 Francisco, California. 20 I then completed a neurology residency from 21 1996 to 1999 at Tufts New England Medical Center. 22 I then completed three fellowships at the 23 Cleveland Clinic between 1999 and 2002 in 24 vascular neurology, neurological critical care, and 25 intra-vascular neurology. 0006 1 Q. And what is your current position? 2 A. I am an associate professor of neurology. 3 Q. At the University of Louisville? 4 A. University of Louisville, Ken -- yes. 5 Q. And are you engaged in any special area 6 of neurology? 7 A. Stroke neurology. 8 Q. Are you considered an interventionalist? 9 A. I am. 10 Q. And I'm going to be asking you some 11 questions about your involvement with the patient 12 by the name of Shannon Sullivan back in August of 13 2006 at the Cleveland Clinic. Were you employed 14 by the Cleveland Clinic back in August of 2006 15 when you were involved in his care? 16 A. Yes. 17 Q. We've been talking for five or ten minutes 18 now. Can you hear me okay? 19 A. I can. 20 Q. Doctor, with respect to the remainder of 21 the deposition, if I ask you a question that you 22 don't understand, please tell me that, I will restate 23 it to your satisfaction. Likewise if you -- if I cut 24 you off, I promise you that I did not do so 25 intentionally. I want to give you every opportunity 0007 1 to answer fully, accurately, and carefully. So 2 please tell me if I have cut you off; okay? 3 A. Okay. 4 MS. CARULAS: Hey, Dave? 5 MR. KULWICKI: Yes. 6 MS. CARULAS: Just for the record, are 7 you just by yourself, or is anyone with you? 8 MR. KULWICKI: I am by myself. 9 MS. CARULAS: Okay. Thank you. 10 BY MR. KULWICKI: 11 Q. All right. And likewise, Doctor, if you 12 need to take a break or confer with counsel, just 13 let me know that and we'll -- we'll accommodate 14 you for -- for that as well. 15 And finally, you're doing a great job of letting 16 me finish my question. Sometimes I'll stumble 17 through a question and it takes me a second to 18 finish it. But please be patient with me, as you've 19 done so far, and we'll -- we'll get through this 20 okay; all right? 21 A. All right. 22 Q. I take it you're board certified in 23 neurology; is that correct? 24 A. Yes. 25 Q. Any other specialties? 0008 1 A. Vascular neurology. 2 Q. Back in August of 2006, were you an 3 attending physician? 4 A. Yes. 5 Q. And as part of your duties, did you 6 administer intra-arterial or intravenous 7 thrombolytics? 8 A. Intravenous thrombolytics. 9 Q. Do you currently administer intra-arterial 10 thrombolytics? 11 A. Yes. 12 Q. When did you start doing that as part of 13 your practice? 14 A. When I came to University of Louisville. 15 Q. Did you train in doing intra-arterial 16 thrombolytic administration at the Cleveland 17 Clinic? 18 A. Yes. 19 Q. And why would it be that you didn't do it 20 at the clinic but now you do it at Louisville? 21 A. Because that was the policy of the clinic 22 at the time. 23 Q. And -- and just tell me what that policy 24 was. 25 A. The policy was that intra-arterial 0009 1 thrombolysis would be performed by neurosurgery 2 or interventional neuroradiology. 3 Q. I had the opportunity to depose one of the 4 residents in August of 06, Dr. Bermel. Have you 5 had a chance to read Dr. Bermel's deposition? 6 A. Only briefly and in part. 7 Q. What other materials did you review in 8 preparation for today's deposition? 9 A. The records of Shannon Sullivan provided 10 me by counsel. 11 Q. Anything else? 12 A. No. 13 Q. Did you look at any films, by any chance? 14 A. No. 15 Q. Dr. Bermel talked about a -- a -- a 16 pneumonic code or page reference that was in 17 place in the clinic at -- in -- in August of 06, and 18 he referred to it as two-clot, numeric two-clot; are 19 you familiar with that term? 20 A. Yes. 21 Q. And what that does that refer to? 22 A. That's the stroke pager, the acute stroke 23 pager at the Cleveland Clinic. 24 Q. And then he also referred to a two-flow 25 pager identification. What -- what does that mean 0010 1 to you? 2 A. That's the interventional team acute 3 pager. 4 Q. Now, you mentioned earlier that the 5 policy of the clinic in 2006 was for intra-arterial 6 thrombolytic neurosurgery or interventional 7 radiology would perform or administer that -- 8 that -- that procedure. How about with respect to 9 intravenous TPA? Would neurosurgery or 10 interventional radiology perform that procedure? 11 A. No. 12 Q. Who -- who would do that? 13 A. The stroke team. 14 Q. How many stroke teams were there at the 15 clinic in 2006? 16 A. One. 17 Q. And how many attendings were designated 18 to be on call or on service for the stroke team at 19 any given time? 20 A. One. 21 Q. Would the -- would the stroke team, the 22 acute stroke team respond to presumptive embolic 23 and hemorrhagic strokes both? 24 A. Primarily embolic. Rarely hemorrhagic. 25 Q. Were you involved at all in developing the 0011 1 stroke team or creating policies or procedures that 2 applied to the stroke team? 3 A. No. 4 Q. Were there policies and procedures in 5 place in 2006 that pertain to the activities of the 6 stroke team? 7 A. Yes. 8 Q. And what would those be called or 9 referenced as? 10 A. I don't know. 11 Q. Okay. What was the purpose, to your 12 understanding, of the stroke team? 13 A. To evaluate and treat patients with 14 stroke. 15 Q. Was it one purpose to rapidly respond to 16 acute strokes within the hospital? 17 A. Yes. 18 Q. And would you agree that when it comes 19 to treating thromboembolic strokes that time is of 20 the essence? 21 A. Of course. 22 Q. I think I've seen a slogan of late that said 23 something like "time is brain." Have you seen 24 that? 25 A. Yes. 0012 1 Q. And do you subscribe to that slogan? 2 A. Yes. 3 Q. Besides a neurology attending, what 4 other members made up the stroke team at 5 Cleveland Clinic in 2006? 6 A. The -- the house staff, as well as a 7 fellow. Although, I don't recall if we had a fellow 8 in 2006. I'm sorry. And -- and nurses, as well. 9 Q. Okay. Back in August of 2006, did you 10 have a standard shift where you were on call as 11 part of the stroke team? 12 A. I don't recall if that was my standard shift 13 or if I was covering for someone that night, but we 14 did have a call schedule. 15 Q. And in terms of staffing, how did that 16 normally work? Were there two 12-hour shifts per 17 day, or some other arrangement? 18 A. No. Normally, 24/7 for two to four weeks. 19 Q. And let me just try to understand that. 20 Would it be -- well, obviously, it wouldn't be one 21 attending who would be on call 24/7 for two to four 22 straight -- for two to four weeks; correct? 23 A. No, that's incorrect. We would be on call 24 24/7 for two to four weeks. 25 Q. Okay. And -- and I apologize. I'm 0013 1 certainly not trying to rake you over the coals 2 here, but it -- it was a little difficult to understand 3 that. And -- and let me just re-ask so -- re-ask so 4 I'm sure I understand correctly. 5 So, in terms of staffing the acute stroke team 6 at the Cleveland Clinic in 2006, there would be 7 one attending who would be designated to staff 8 that -- that particular service during the two to 9 four-week period; correct? 10 A. Yes. 11 Q. And if you were not physically in the 12 hospital, how would you be reached? 13 A. You're cutting out. 14 Q. Okay. So, during the period of time when 15 you would be the staff member who was on service 16 for the acute stroke team, if you were not 17 physically present at the hospital when an acute 18 stroke arose, how would you be contacted? 19 A. Pager. 20 Q. Was this a personal pager, or something 21 that was issued by the Cleveland Clinic? 22 A. It was issued. 23 Q. Do you know if there is a log of pages, a 24 pager log that is checked relative to pages made 25 to you during this time frame? 0014 1 A. I do not. 2 Q. Did you keep any records separate and 3 apart from a patient's hospital record that would 4 reflect your activities as part of the stroke team? 5 A. No. 6 Q. Were there times when you were the staff 7 member manning the acute stroke team where you 8 would be at the hospital engaged in other medical 9 activities? 10 A. Yes. 11 Q. And what kind of practice did you run in 12 August of 06 outside of the stroke team? 13 A. Could you rephrase that, please? 14 Q. Sure. I'm asking about your -- your 15 clinical duties, other than the stroke team, during 16 the time frame where you would be the staff 17 attending designate -- designated to man the 18 stroke team? 19 MS. CARULAS: I'm just -- I'm just going 20 to object because I don't see how it's relevant. I 21 mean, he'll tell you in this case he was home when 22 all this took place. But go ahead, I mean, 23 generally. 24 A. So, during -- during the day, you're -- 25 you're asking; correct? 0015 1 BY MR. KULWICKI: 2 Q. Yes. 3 A. Yeah. I would have outpatient clinic, or I 4 would perform diagnostic cerebral angiograms one 5 day a week, approximately. 6 Q. Were there written policies or procedures 7 at the Cleveland Clinic in August of 2006 that 8 pertain to the administration, the intravenous 9 administration of thrombolytics in acute stroke 10 patients? 11 A. I don't know because I'm not sure when 12 we received primary stroke center designation. 13 Q. Can -- can you say that again? I'm -- I 14 apologize. I didn't hear you. 15 A. I -- I -- I do not know. 16 Q. Are you familiar with a document called 17 the "Cleveland Clinic IV TPA [sic] Faxable Protocol 18 Checklist"? 19 A. No. 20 Q. Referencing your research activities and 21 areas of interest, have you been involved in any 22 research relative to IV administration of 23 thrombolytics in acute stroke patients? 24 A. I am currently. 25 Q. Okay. Are those activities recorded in 0016 1 any publication, any, you know, journal articles or 2 the like? 3 A. Which activities? 4 Q. Research into intravenous administration 5 of thrombolytics. 6 A. My activities or the activities of others? 7 I -- I'm -- 8 Q. Your -- yours. 9 A. I don't think I have published on IV TPA. 10 Q. Have you published on intra-arterial TPA 11 or thrombolytic therapy? 12 A. Yes. 13 Q. Was that an area of interest when you 14 were at the Cleveland Clinic? 15 A. Yes. 16 Q. Are the -- the studies that you were 17 involved in at the clinic recorded in your CV? 18 A. Yes. 19 Q. Were the results of the PROACT I and the 20 PROACT II studies published prior to August of 21 2006? 22 A. Yes. 23 Q. And do those studies demonstrate 24 efficacy of intra-arterial thrombolytics in the 25 treatment of acute thromboembolic stroke? 0017 1 A. No. 2 Q. Do you have an understanding of what 3 criteria were used for the use of intra-arterial 4 thrombolytics at the clinic in August of 2006? 5 MS. CARULAS: I'm going to object. 6 That's awfully broad. 7 A. Yes, very broad. 8 BY MR. KULWICKI: 9 Q. Well, let's see if I can narrow it down. 10 And I'm talking about in the context of a case like 11 this in a patient with a acute thromboembolic 12 stroke demonstrated on CT with clinical signs or 13 symptoms of stroke. 14 MS. CARULAS: Same objection. 15 A. I mean, it's -- it's a -- it's a broad 16 question. I'm not sure how to answer it. There 17 were -- 18 BY MR. KULWICKI: 19 Q. I -- go ahead. 20 A. No. Go ahead. I'm sorry. 21 Q. Do you know who the attending was that 22 was manning the two-flow service at the time of 23 Mr. Sullivan's stroke evaluation? 24 A. I am not certain, but I assumed in 25 reviewing this record it was Dr. Rasmussen. 0018 1 Q. And what specialty of medicine is Dr. 2 Rasmussen? 3 A. Neurosurgery. 4 Q. In the context of this case, would he 5 likely have been the individual who made the 6 determination as to whether or not Mr. Sullivan 7 was a candidate for intra-arterial thrombolytic 8 therapy? 9 A. Are you asking me to speculate? 10 Q. No. I'm asking you if you -- if you can 11 tell from review of the record or based on your 12 personal knowledge of what happened in this 13 clinical setting? 14 A. I don't know if he made that decision 15 personally. I can't -- I can't answer that. 16 Q. Okay. In terms of how things were 17 supposed to work back at the Cleveland Clinic in 18 August of 2006, would it likely have been Dr. 19 Rasmussen who would make that determination? 20 A. Yes. Generally speaking, the attending 21 interventionalist on call would make that decision. 22 Q. My research tells me that the clinic is an 23 acute stroke -- stroke center today. Do you know 24 if it was an acute stroke center in August of 2006? 25 A. I don't know what "acute stroke center" 0019 1 means. 2 Q. Okay. 3 A. But if -- if you mean we treated strokes, 4 yes. 5 Q. If I mean what? 6 A. That we treated strokes, the answer is 7 "yes." 8 Q. Point of clarification. I've been using the 9 term "stroke team" or "acute stroke team." And I 10 picked that up from, I think, Dr. Bermel's 11 deposition or somewhere else in the record. 12 And just so that we're clear and I'm using it 13 correctly, does that refer to the two-clot service, 14 or does it refer to both the two-clot service and 15 the two-flow service together? 16 A. Two-clot. 17 Q. With respect to the acute stroke service, 18 was there a standing order with respect to getting 19 the patient imaged as quickly as possible after 20 there was, quote, unquote, "concern for a stroke"? 21 A. I don't understand your question. 22 Q. Yeah. Let me ask it a different way and 23 maybe we can make it easier. 24 Tell me, what was the practice of the acute 25 stroke team back in August of 2006 when 0020 1 responding to a patient who had apparent signs or 2 symptoms of a stroke? 3 A. Rapid evaluation. That -- that included a 4 physical examination and CAT scan. 5 Q. Were there any time parameters set for 6 how quickly the CAT scan and physical 7 examination needed to be completed? 8 MS. CARULAS: Objection. 9 A. Immediately -- or -- or, well, no, I take 10 that back. More precisely, as rapidly as possible. 11 BY MR. KULWICKI: 12 Q. Do you have any recollection in August of 13 2006 of having a situation arise at the Cleveland 14 Clinic where a CT scanner was not available when 15 needed for rapid evaluation of a suspected stroke 16 patient? 17 MS. CARULAS: Objection. I don't -- I 18 don't see how that's relevant to this since there 19 was a CAT scanner. But go ahead. 20 THE WITNESS: Should -- should I 21 answer? 22 MS. CARULAS: Yeah. 23 A. I have no -- no recollection of such an 24 event. 25 BY MR. KULWICKI: 0021 1 Q. Okay. Doctor, do you recall this 2 particular patient? 3 A. After reviewing the chart, yes, I have 4 some recollection. 5 Q. And do you have a recollection, sense of 6 you recall what the patient looks like such that you 7 could describe him? 8 A. No, I don't think so. 9 Q. Okay. Is it -- and -- and let me just try to 10 understand. Is your recollection limited to the 11 information contained in the medical chart? 12 A. Yes. 13 Q. Back in August of 2006, as an attending 14 on the stroke team, would you, yourself, actually 15 review CT imaging? 16 A. Yes. 17 Q. And what was the purpose of the CT 18 scan? 19 A. To exclude intracellular hemorrhage, 20 define the size of the stroke, and see if the patient 21 is a candidate for therapy or not. 22 Q. On CT imaging in the context of an acute 23 stroke, can you differentiate between areas of 24 ischemia and areas of infarct? 25 A. No. Well, let me -- let me take that 0022 1 answer back. Actually, that's a pretty broad 2 question. Could you be more specific? 3 Q. Sure. And maybe I should define how I'm 4 using those terms. When I talk in terms of 5 ischemia, I'm talking about areas where brain 6 tissue has been deprived of oxygen. And when I 7 talk about infarct, I'm talking about areas where 8 brain tissue has been deprived of oxygen for so 9 long that it is, you know, dead, it's -- it's not 10 reviveable. 11 So my question is: Can you tell on a CT scan 12 when looking at abnormal areas in the area or the 13 distribution of a stroke, can you differentiate 14 between areas that are damaged but retrievable 15 and areas that are damage -- damaged but not 16 retrievable? 17 MS. CARULAS: And I'm just going to 18 note a continuing line of objection to this that 19 while Dr. Abou-Chebl says he, on occasion, looks 20 at these films that he is not a neuroradiologist. 21 But go ahead. 22 A. On a CAT scan, all you can tell is 23 whether there are areas of damage or not. 24 BY MR. KULWICKI: 25 Q. With respect to your review of CT scans, 0023 1 do you have an understanding or a part of your 2 training where you've learned how long it takes for 3 an area of damage to be visible on a CT scan? 4 A. Yes. 5 Q. Go -- go ahead. 6 MS. CARULAS: Note an objection. Go 7 ahead. 8 A. Yes. I -- I said -- that -- that's the 9 answer, yes. 10 BY MR. KULWICKI: 11 Q. And how long? 12 A. Typically, a few hours. 13 Q. Did you review the official interpretation 14 of the first post-stroke CT scan in this particular 15 chart? 16 A. Yes. I -- I have read the reading 17 supplied in the record here. 18 Q. And do you take tissue with that in any 19 respect or have any difference in terms of your 20 interpretation of the CT scan than what's recorded 21 in that official report? 22 A. No. 23 Q. Would you agree that Mr. Sullivan, based 24 on the initial CT scan on August 17, had a 25 well-established stroke based on CT scan and 0024 1 clinical findings? 2 A. It would appear so. 3 Q. And can we agree that if the CT scan was 4 taken earlier that there would be a lesser area of 5 damage demonstrated on the film? 6 MS. CARULAS: Objection. 7 A. I think that's -- you're asking me to -- you 8 know, for conjecture there. There's -- there's no 9 way to answer that. 10 BY MR. KULWICKI: 11 Q. Okay. Are you familiar with the American 12 Stroke Association's guidelines for early 13 management of patients with ischemic stroke? 14 A. Yes. 15 Q. Were those guidelines followed by you 16 while you were at the Cleveland Clinic in August of 17 2006? 18 MS. CARULAS: Objection, given the fact 19 that they're guidelines. But go ahead. 20 A. Yeah. Yes, we generally follow the 21 guidelines. 22 BY MR. KULWICKI: 23 Q. And would you agree that the -- the 24 document, the American Stroke Association 25 guidelines for the early management of patients 0025 1 with ischemic stroke as published in the journal 2 Stroke are reliable -- a reliable resource for 3 determining the indications for IV thrombolytics? 4 A. They're one of the tools we use. 5 Q. Okay. What other tools would you use 6 back in August of 06? 7 A. Clinical judgment and experience. 8 Q. Okay. Any other consensus statement, 9 guidelines, publications, or other publications that 10 you would reference or rely upon for the 11 indications for IV thrombolytics in August of 2006? 12 A. Would you like me to recite the entirety 13 of Medline pertaining to treatment of stroke? I 14 mean, that's a pretty broad question. 15 Q. Okay. Yeah, I understand. I know 16 there's a lot written. What I'm -- and -- and I 17 think you encompassed that with respect to 18 referencing your training and experience. 19 What I'm asking for is any type of sort of 20 watershed consensus statement or set of 21 guidelines or anything that might be as 22 authoritative or more authoritative than the stroke 23 guidelines that we referenced earlier. 24 A. I -- I can't recall any right now. 25 Q. All right. By way of history -- and I'm -- 0026 1 I'm referencing testimony from Dr. Bermel, the 2 senior stroke resident who was involved with Mr. 3 Sullivan's care. 4 It appears that the last normal assessment of 5 the patient was recorded on August 17 at 2030, 6 that the stroke team was activated on August 17 at 7 2115, and then we have a note from Dr. Taub on 8 August 17 at 2130. She was the junior stroke 9 resident, and it looks like she was the first 10 responder. 11 Do you have Dr. Taub's notes handy? I think I 12 sent them with the court reporter and marked those 13 as Bermel Exhibit 2. And it would be Page 2 of 14 Exhibit 2. And why don't you get that, Doctor. I 15 want to ask you some questions about that. 16 A. I have that, but -- but I would like to just 17 say that I think you said the statement that -- I'm 18 not sure there's facts to support it. You said Dr. 19 Taub was the first responder. I don't know how we 20 know that. 21 Q. Okay. Fair enough. Do you know who the 22 first responder was? 23 A. I do not. 24 Q. And I appreciate you clarifying that 25 because I guess I -- I -- I said that, but there may 0027 1 have been a nurse who was there first. Are you 2 aware of any physician who attended to Mr. 3 Sullivan after his first signs or symptoms of a 4 suspected stroke arose other than Dr. Taub? 5 A. There's a note at 9:15 p.m. from a 6 cardiology fellow or resident. I'm not sure which. 7 Q. Let's talk about that note. Is there a 8 distinction between the cardiology service and the 9 EP service back in August of 2006? 10 A. I don't know that. 11 Q. And with respect to that cardiology note 12 at 9:15 p.m., there is -- about halfway down 13 there's a note that says, "Will need STAT head 14 CT," and then there is a note after that. Can you 15 interpret that? Does that mean anything to you? 16 It looks like "MR something per NRO." 17 A. I do not know what that means. If -- if 18 you can interpret the -- the writing there, I'll try to 19 make sense of what I can. But I can't -- I don't 20 know what NRO is. 21 Q. Fair -- fair enough. I was just wondering. 22 I can't and I just thought maybe you could, but. . . 23 All right. Let's go to Page 2. And in light of 24 that clarification, let's look at Dr. Taub's note. 25 Her note is -- covers about three pages, and to the 0028 1 left of it there is handwriting in a different 2 handwriting, apparently. Is that your handwriting 3 in the left margin? 4 A. Yes. 5 Q. Okay. And if we go to the end of Dr. 6 Taub's note, there's a note on August 18 at 9:22 7 a.m. that says, "Agree" -- begins, "Agree with 8 above"; is that your handwriting, as well? 9 A. Yes. 10 Q. Okay. Was both the marginalia next to 11 Dr. Taub's note and your note beginning with 12 "Agree with the above," were both of those written 13 at 9:22 a.m.? 14 A. Yes. 15 Q. Was that the first time that you saw the 16 patient? 17 A. Probably immediately before that. 18 Q. Do you know if any other stroke attending 19 saw the patient between 9:15 p.m. on August the 20 17 and August 18 just before 9:22 a.m. when you 21 first saw the patient? 22 A. I do not. 23 Q. Do you have any recollection of being in 24 contact with the stroke residents relative to this 25 patient prior to your assessment, in-person 0029 1 assessment of the patient on August 18? 2 A. Yes. 3 Q. Tell me what you recall. 4 A. I get called about every stroke patient by 5 the residents, and we discussed the case. That's 6 what I recall. 7 Q. Would you agree that that was the policy 8 of the Cleveland Clinic back in 2006 that the 9 stroke residents are supposed to contact the 10 stroke attending relative to each and every patient 11 who is -- has a presumed stroke or suspected 12 stroke? 13 A. Yes. 14 Q. Do you have any independent recollection 15 of being contacted relative to this patient? 16 A. Could you rephrase, please? 17 Q. Sure. Do you have a specific recollection 18 relative to being contacted about this patient? 19 A. After reading the chart, you know, I 20 remember discussing the case with Bermel, but 21 that's the extent of -- is that what you mean? 22 Q. Well, the very last thing in Dr. Taub's 23 note is, "Will discuss with staff in a.m." And to 24 me, that means Dr. Taub is planning to discuss 25 this with you, as the staff member designated for 0030 1 the stroke team. Do you interpret that the same 2 way? 3 MS. CARULAS: Objection. 4 A. Well, that's what she wrote, so whatever 5 she wrote. But we didn't get called by the juniors 6 anyways, we got called by the senior residents. 7 MS. CARULAS: And that's at the end of 8 a whole bunch of orders that are initiated at the 9 end of all of the discussion, obviously. But go 10 ahead. 11 BY MR. KULWICKI: 12 Q. And what I'm asking, Doctor, is: Do you 13 have a specific recollection of being contacted by 14 a stroke resident relative to this patient? 15 A. I already answered that question as 16 "yes." 17 Q. Okay. Is that charted anywhere, that 18 discussion? 19 A. I believe Dr. Bermel wrote that he 20 discussed with staff. 21 Q. I take it you agree that the patient was 22 not a candidate for IV thrombolytics; correct? 23 A. Correct. 24 Q. And tell me each and every reason why. 25 A. Well, I -- I wrote the reasons in my note. 0031 1 These included primarily a low benefit to risk 2 ratio, including the evidence of infarct on CT, the 3 lack of mismatch on CT perfusion, the recent 4 cardiac oblation, the mildly elevated INR. Those 5 would have all been factors. 6 Q. Okay. 7 A. The -- the -- the location of the 8 occlusion. 9 Q. Anything else? 10 A. That's all that I -- I can recall right now. 11 Q. All right. You gave me a list of several 12 items, and unfortunately, you sort of cut out on -- 13 at the beginning. The first thing you said was the 14 evidence of infarct on CT, and then the second 15 thing I didn't quite get. Do you remember what 16 that was? If not, we can ask the court reporter to 17 read it back to us. 18 THE WITNESS: Can you -- can you read 19 that back, please? 20 MS. CARULAS: I think it was a mismatch 21 on a perfusion. 22 THE REPORTER: "These included 23 primarily a low" -- I don't know if he can hear me. 24 Can you hear me? 25 MR. KULWICKI: Yes. 0032 1 THE REPORTER: Okay. "These included 2 primarily a low benefit to risk ratio, including the 3 evidence of infarct on CT, the lack of mismatch on 4 CT" -- 5 MR. KULWICKI: Lack of what? 6 THE REPORTER: Mismatch on CT 7 profusion. 8 THE WITNESS: Perfusion. 9 MR. KULWICKI: Okay. Thank you. Now 10 we can go back on the record. 11 BY MR. KULWICKI: 12 Q. Okay. Doctor, I'd like to ask you about 13 each of these items and get a little bit more 14 information about your thought process in August 15 of 2006. 16 With respect to the evidence of CT on -- or 17 evidence of an infarct on CT, tell me what it was 18 about that that led you -- that -- that sort of 19 weighed against giving IV thrombolytics? 20 A. That there was evidence -- and as Dr. 21 Ruggieri wrote of the -- right MC distribution 22 infarct clearly involving more than one-third of the 23 right MC territory. 24 Q. Would you agree that the presence of 25 early infarct signs, even if involving greater than 0033 1 one-third of the MCA territory in August of 06 in 2 patients with a well-established stroke having an 3 onset time of less than three hours, does not or 4 did not preclude treatment with IV TPA or suggest 5 an unfavorable outcome to therapy? 6 MS. CARULAS: Objection. 7 A. And -- and -- and I disagree. 8 BY MR. KULWICKI: 9 Q. All right. Are you aware of any literature 10 that would support your position relative to the 11 extent of MCA territory that would counsel in favor 12 of or against IV thrombolytics? 13 A. There are several publications. The most 14 important of which is the ECASS II trial. 15 Q. Tell me that one again. 16 A. ECASS II, E-C-A-S-S, Roman numeral II. 17 Q. And is that published in Stroke? 18 A. I don't recall where it was published. 19 Actually ECASS I and II. 20 Q. Second thing that you referenced was 21 the -- and -- and forgive me, the court reporter 22 reread this but I'm not sure I fully appreciate what 23 was said. The lack of mismatch on the CT 24 perfusion? 25 A. That's what I said; yes. 0034 1 Q. Okay. And tell me what that means, 2 Doctor. 3 A. That means that there was no measurable 4 penumbra, and therefore, no salvageable tissue. 5 Q. Is that based exclusively on imaging 6 findings? 7 A. That's the CT perfusion result. 8 Q. Did you have the capability of reviewing 9 films at home back in 2006? 10 A. No. 11 Q. How would you have determined about the 12 lack of mismatch on CT perfusion? Would that be 13 related to you by the senior stroke resident or 14 someone else? 15 A. Whomever. The resident, the 16 neuroradiologist, whomever I could get that 17 information from. 18 Q. The next thing you mentioned was recent 19 oblation. Tell me what your consideration was 20 with respect to that item. 21 A. Well, an exclusion of criteria for TPA is 22 something as major surgery within 14 days. That's 23 not defined and there is a well-known risk of 24 cardiac tamponade and pericardial fusion 25 post-oblation. So the concern obviously would be 0035 1 with systemic thrombolysis, the induction of 2 cardiac tamponade, and rapid death. 3 Q. Do you know whether the 4 electrophysiology service that had operated on 5 this patient prior to the stroke was consulted as 6 part of the consideration of whether the patient 7 was a candidate for intra-arterial or intravenous 8 thrombolytics? 9 A. I don't know the timing of -- of the 10 discussions with them, but it is generally our 11 policy to have discussions with the service before 12 initiating therapy. But we never got to that point 13 with this man. 14 Q. Why is that? 15 A. Because he wasn't a candidate for IV 16 TPA. 17 Q. The fourth item you mentioned was the 18 mildly elevated INR. And tell me how that was a 19 factor that weighed against IV TPA? 20 A. It's an exclusion to give IV TPA to 21 patients with an INR greater than 1.5. His wasn't 22 1.5, it was 1.4. So it's yet another factor that I 23 have to consider. 24 Q. And then the last item that you listed for 25 us that weighed against IV TPA was the location of 0036 1 the occlusion. And tell me how that factored in. 2 A. Carotid terminus occlusion has an, 3 approximately, 8% recanalization with the IV TPA. 4 And so there was low probability of benefit from 5 the TPA. 6 Q. With respect to the screening, NIH stroke 7 scale that was performed on Mr. Sullivan, did the 8 results of that weigh against giving IV TPA? 9 A. Yes and -- yes and no. 10 Q. Explain that. 11 A. The more severe the stroke, the less 12 likely the benefit. Although his score did not meet 13 the threshold for being an absolute exclusion. 14 Q. Can we agree that the documented onset 15 of his stroke was within three hours or less than 16 three hours? 17 A. Based on last normal, yes. 18 Q. Can we agree there was no hemorrhage 19 indicated on the CT scan? 20 A. I'll have to reread this, but let's see. 21 Give me a second while I read it and make sure he 22 says here specifically no hemorrhage. 23 Yes. Per Dr. Ruggieri's reading, there's no 24 evidence of acute parenchymal hemorrhage. 25 Q. Can we agree that his blood pressure 0037 1 parameters did not constitute an exclusion -- or 2 meet exclusionary criteria for IV TPA? 3 A. Yes. 4 Q. Can we agree that his symptoms were not 5 rapidly improving or minor? 6 A. Yes. 7 Q. Can we agree that he did not have a 8 documented seizure at the onset of a stroke? 9 A. Yes. 10 Q. Can we agree that he did not have a 11 stroke within the three months prior to this stroke? 12 A. I don't know. 13 Q. You're not aware of any? 14 A. Correct. 15 Q. And you're not aware of any history of 16 head trauma within three months prior to the 17 stroke; correct? 18 A. Correct. 19 Q. Is it your belief that the -- the oblation 20 procedure falls within the -- the characterization 21 of major surgery? 22 A. Yes. 23 Q. You're not aware of any history of 24 intracranial hemorrhage in this patient prior to the 25 stroke; correct? 0038 1 A. Correct. 2 Q. Not aware of any GI hemorrhage or 3 urinary tract hemorrhage within 21 days of this 4 stroke; true? 5 A. There's none noted. 6 Q. And you weren't aware of any? 7 A. Correct. 8 Q. And likewise, you weren't aware of any 9 arterial puncture at a non-compressive site within 10 21 days of the stroke; true? 11 A. Correct. 12 Q. Do you know if the risks and benefits of 13 thrombolytic therapy were discussed with the 14 patient or the patient's representative? 15 A. I do not. 16 Q. Was it your belief that the patient was 17 anti-coagulated at the time consideration was 18 given to whether he was a candidate for TPA 19 administration? 20 A. Please rephrase that question or clarify 21 it. Yeah. 22 Q. Well, can we agree that a patient's taking 23 anti-coagulants or receiving heparin within 48 24 hours of a stroke is considered an exclusion 25 criteria? 0039 1 A. In part, yes. 2 Q. Okay. Did -- did that exclusion criteria 3 apply to him? 4 A. Well, I believe the exclusion criteria 5 states that you have to have an elevated PTT, and 6 I'm trying to see what the lab here -- his -- I don't 7 see notation of the PTT here. 8 Q. If his PTT and -- or PT -- I'm sorry. If his 9 PTT was not elevated or his PT was less than 15, 10 would he meet the exclusion criteria for anti- 11 coagulation? 12 MS. CARULAS: I'm going to -- I'm just 13 going to keep objecting to this whole idea of 14 exclusion criteria and so forth. You're -- you're 15 actually looking at the -- the American Stroke 16 Association listing here of -- of who could be 17 treated with TPA? Is that what you're -- 18 MR. KULWICKI: I'm asking this 19 physician based on his experience and training. 20 MS. CARULAS: Okay. I think he's 21 already testified, however, they noted -- didn't 22 even get to that because he didn't feel the patient 23 was a candidate. But go ahead. I just want to 24 make sure we're on the same page. 25 MR. KULWICKI: Oh, Anna, we're never 0040 1 on the same page. 2 MS. CARULAS: That's true. 3 A. Okay. So I already said that the 4 exclusion criteria would be an INR greater than 5 1.5. His was 1.4. So this was another factor that 6 I considered but not by itself an exclusionary 7 factor. 8 BY MR. KULWICKI: 9 Q. Okay. I understand that platelet counts 10 below 100,000 can be an exclusion criteria; would 11 you agree with that? 12 A. Yes. 13 Q. And his were greater than 100,000; true? 14 A. Yes. 15 Q. Were his glucose levels such that that 16 would not be an exclusion criteria for him? 17 A. His glucose levels were normal. 18 Q. All right. Was TPA available for this 19 patient if the decision had been made to 20 administer it? 21 A. Yes. 22 Q. Doctor, when you give or when you 23 obtained an informed consent from a patient to 24 administer TPA back in August of 2006 in a 25 situation where the patient was un -- unconscious 0041 1 or not able to give consent, what was the practice 2 at the Cleveland Clinic again back in August of 3 2006 with respect to appropriate setting -- in that 4 setting? Would you talk to the patient's spouse or 5 some other mechanism? 6 A. Well, actually, we did not have to obtain 7 informed consent because TPA was an approved 8 treatment under emergency conditions. But 9 nevertheless, we always try to speak with the legal 10 next of kin, whoever that would be. 11 Q. Okay. And with respect to that 12 discussion, were -- was -- was it the clinic's 13 position that you would discuss with the patients 14 or the patient's legal representative the true and 15 accurate risks and the true and accurate benefits 16 of TPA? 17 MS. CARULAS: Ob -- objection. 18 A. Are -- are you speaking generally, or 19 regards to this patient? 20 BY MR. KULWICKI: 21 Q. Generally. 22 A. Generally, yes. 23 MS. CARULAS: Note the objection. 24 A. Well, yes. We -- we discuss risk and 25 benefits. 0042 1 BY MR. KULWICKI: 2 Q. Doctor, I apologize for asking these 3 questions, but what was your reason for leaving 4 the Cleveland Clinic? 5 MS. CARULAS: Note objection. Go 6 ahead. 7 A. I had a better opportunity. 8 BY MR. KULWICKI: 9 Q. Have your privileges at any hospital been 10 revoked suspended or called into question in any 11 manner? 12 THE WITNESS: Do I have to answer 13 that? Is that -- do I have to -- he's asking about 14 my privileges and credentials and all that. Okay. 15 MS. CARULAS: No. Wait a minute. Just 16 give us a minute here; okay? 17 MR. KULWICKI: Sure. 18 [WHEREUPON, an off-the-record discussion is 19 held.] 20 BY MR. KULWICKI: 21 Q. Okay. 22 A. The -- the answer is "no." 23 Q. Okay. 24 MS. CARULAS: You know, I had one 25 thing, too, Dave, I just wanted to -- to clarify. You 0043 1 had asked a lot of questions about whether or not 2 in general he discusses risks and benefits of TPA 3 or has his staff do that in a general sense, and 4 you didn't ask about this particular case. 5 And I just want you to know his testimony 6 would be that, in this particular case and in cases 7 where he does not believe it's an option, he does 8 not then go and tell them about it if he doesn't 9 believe it's an option. So -- 10 MR. KULWICKI: Well, I think that -- I 11 think that was clear. 12 MS. CARULAS: Okay. I just wanted -- 13 you know, he only has this risk-benefit discussion 14 if he believes the patient's a candidate. 15 MR. KULWICKI: Right. 16 MS. CARULAS: So I just wanted to be 17 sure you were clear on that. 18 BY MR. KULWICKI: 19 Q. And, Doctor, again, I apologize. Has 20 your license to practice medicine in any state been 21 revoked, suspended, or called into question in any 22 respect? 23 A. No. 24 Q. Have you ever been a subject of 25 disciplinary proceedings before any medical board 0044 1 or hospital staff? 2 A. No. 3 [WHEREUPON, off-the-record remarks are 4 made.] 5 BY MR. KULWICKI: 6 Q. I'm making good progress here. Bear 7 with me. I'm just kind of crossing off things that 8 I've covered. 9 MS. CARULAS: Yeah, take your time. 10 BY MR. KULWICKI: 11 Q. Doctor, my review of the records indicate 12 that it took, approximately, two hours from the 13 time the stroke team was first activated to the time 14 that the -- the CT results were available. And 15 first, is that consistent with your review of the 16 record? 17 A. I did not look -- I don't know how to 18 answer that because I don't know what time the CT 19 results were officially interpreted. But I'll tell you 20 that is definitely not consistent with our practice. 21 Q. Would you agree that that would be too 22 long of a period of time from the time that stroke 23 team is activated from the time that CT results 24 would be available? 25 MS. CARULAS: Note an objection. 0045 1 A. Again, it depends on the stability of the 2 patient. Some patients you can't get a CT on that 3 quickly. 4 BY MR. KULWICKI: 5 Q. Is there any reason to -- do you have any 6 facts to support that you couldn't get a CT on Mr. 7 Sullivan quickly because of his clinical status? 8 A. It was my recollection that the CT was 9 obtained very quickly. 10 Q. In assuming it took two hours from the 11 time the stroke team was activated to the time the 12 CT results were available, do you have an 13 explanation for why it took two hours? 14 A. Well, I think -- 15 MS. CARULAS: Objection. 16 A. -- you're making that assumption. I'm not 17 going to make that assumption. 18 BY MR. KULWICKI: 19 Q. Well, I -- I -- Doctor, can we agree that 20 not -- that there's no explanation in this record 21 that would support why there would be a lapse of 22 two hours from the time the stroke team was 23 activated to the time that CT was performed on the 24 patient? 25 A. Give me -- give me -- give me one 0046 1 second, please. 2 MS. CARULAS: Note my objection. 3 A. Okay. I -- I see what you're saying that 4 this note from Dr. Ruggieri says, [reads] The 5 on-call senior resident was notified of these 6 results at 11:15. 7 That may be when Dr. Ruggieri noted it, but I 8 know that as a matter of practice that our 9 residents accompany the patients to CAT scan, 10 look at the CAT scan, and they call the stroke 11 attending immediately with their interpretation. 12 And so, just because Dr. Ruggieri officially 13 typed up his note, does not mean we were not -- 14 we weren't -- we didn't have the results an hour or 15 hour and a half before then. 16 BY MR. KULWICKI: 17 Q. Is there any documentation in the record 18 that supports a contention that the CT results were 19 available before 11:15 on August 17th? 20 A. Well, there's my note that says I see 21 occlusion [reads] was quickly confirmed by the 22 stroke team via CTA/CTP. I don't think I would 23 write "quickly" if it took two hours. In fact, I 24 definitely wouldn't write "quickly" if it took two 25 hours. And I'd have to look through the chart more 0047 1 carefully to be certain. 2 It says here, "Taken for emergency CT." This 3 is Dr. Bermel's note. And again, the term 4 "emergent" means emergent, which means -- and 5 our residents know that within five minutes of 6 arrival they were to quickly assess the patient with 7 an NH score and then proceed to CAT scan. So I 8 would be extremely skeptical that there was a 9 two-hour delay in getting the CAT scan. 10 Q. And if there was a two-hour delay, that 11 would not be acceptable to you, as an attending 12 physician? 13 A. We strive for perfection. 14 Q. Okay. Let's go back to the Bermel 15 Exhibit 2 and Page 2 of that multi-page document. 16 And what I'd like to do, Doctor, your handwriting is 17 very nice, but I would like to have you go through 18 it and just read for us what you wrote. And let's 19 start, if we could, with the marginalia next to Dr. 20 Taub's 2130 note. 21 Can you just -- you know, if you would just 22 briefly read through that, and as you do, interpret 23 hieroglyphics like where it has "2" with a degree 24 sign. You know, just read the word "secondary" -- 25 A. Okay. 0048 1 Q. -- as you go. 2 A. Okay. I wrote first, "Had been on 3 Coumadin pre-procedure." Below that I wrote, "IV 4 TPA not given secondary to recent oblation and 5 jugular and carotid occlusion with less than 8% 6 recanalization efficacy." 7 Q. Before you move on, did you also record 8 the NIHSS evaluation in the left-hand margin? 9 A. No. That's the resident's handwriting. 10 Q. Okay. Thank you. Anything else that you 11 wrote on that page that we just looked at? 12 A. Yes. I wrote to the right, "Last normal at 13 8:30 p.m.," although it looks like an a.m. there. 14 But I assume I meant p.m. And then below that, 15 "Arrived within few minutes." Again, supporting 16 the contention stroke team is there rapidly. That's 17 it for that page. 18 Q. Okay. You know, there are a number of 19 things underlined on that page. Do you know if 20 that was something that Dr. Taub did, or was that 21 something that you would have underlined as you 22 read through the note? 23 A. That's part of what I would have done. 24 Q. Okay. All right. And then on the second 25 page of Dr. Taub's note, is there anything in there 0049 1 that you would have written? 2 A. I wrote, "Left hemineglect." I wrote, 3 "Looks left." And I put, "Questionable left 4 homonymous hemianopsia." 5 Q. And tell me, what was the significance of 6 those left side findings? 7 A. Those support the diagnosis of a right 8 middle cerebral artery stroke. 9 Q. Okay. Anything else on that page that 10 you wrote? 11 A. Not that I can see. 12 Q. Okay. And then on Page 3 of Dr. Taub's 13 note, before we get to your note at 9:22 a.m., did 14 you record anything there? 15 A. Just my hashmarks. 16 Q. Okay. And then if you would, Doctor, do 17 the same thing for us. Read through your note at 18 9:22 a.m. on August 18 and interpret your 19 abbreviations and hieroglyphics as you go. 20 A. Okay. I wrote, "Agree with above. 21 Patient is a 51-year-old male who developed 22 severe right middle cerebral artery syndrome at 23 approximately 8:30 p.m. yesterday following 24 oblation procedure for atrial fibrillation. His 25 initial NIHSS was 16 indicating right MCA or ICA 0050 1 occlusion which was quickly confirmed by the 2 stroke team via CTA/CTP. 3 "Based on these findings and the vascular 4 neurosurgery was consulted for intravascular 5 intervention because I felt revascularization 6 efficacy with IV TPA was poor (approximately 8%) 7 and given the cardiac oblation and jugular 8 puncture, I felt the risk to benefit ratio was too 9 high with a (6% risk of ICH). The endovascular 10 neurosurgery team felt that based on CTA/CTP 11 findings of early injury and a large portion of the 12 MCA with matched perfusion defect there was low 13 likelihood of benefit from revascularization with 14 the risk of ICH. 15 "This was likely due to the carotid T," meaning 16 terminus, "occlusion which effectively decreases 17 collaterals and results in severe limitation of 18 cerebral blood flow greatly limiting the therapeutic 19 window. The prognosis is guarded but I am 20 hopeful given his age he will have good recovery. 21 Recommendations MRI/MRA, hydrate, keep systolic 22 blood pressure 170 to 200, keep glucose less than 23 150 and temperature less than 37 degrees, aspirin, 24 hold anti-coagulants for now (increased risk of 25 ICH." 0051 1 It's cut off there at the bottom. Give me a 2 second. "No hypotonic fluids." And then my 3 signature, Alex Abou-Chebl. 4 Q. And does that complete your note from 5 August 18? 6 A. Yes. 7 Q. Doctor, you used the abbreviation ICH. 8 Is that intracerebral hemorrhage? 9 A. Yes. 10 Q. And then earlier in the note, you 11 reference efficacy, and you have a -- an 8% figure 12 that's quoted there. Tell me again what the 8% 13 refers to. 14 A. Recanalization efficacy. 15 Q. And -- and what does that mean, the -- 16 the -- 17 A. The probability of the TPA opening up the 18 carotid artery to cure the stroke. 19 Q. Is 8% or less? 20 A. Yes. 21 Q. All right. Now, with respect to your 22 prognosis of "hopeful given his age he will have 23 good recovery," did you, at this time, have a 24 prognosis based on the NIHSS score? 25 A. The prognosis was looking at the case in 0052 1 total. 2 Q. Okay. Does the NIHSS score give a 3 prognosis or can be used for prog -- prognostic 4 purposes? 5 A. Absolutely. 6 Q. And with his score of 16, tell me what 7 that tells us about his prognosis. 8 A. Actually, with a score of 16, the 9 prognosis is generally poor. But as I wrote, given 10 his age, I must have felt he looked fit, that I was 11 optimistic or hopeful he could have recovery 12 despite the score. 13 Q. The next note in the progress notes is Dr. 14 Bermel, the neurology senior's note at 9:00 and -- 15 on August 17, and what I wanted to ask you is -- 16 I'm sorry, 10:00 on August 17, 2200. What I 17 wanted to ask you is how it would be that your 18 note would be out of sequence between Dr. Taub's 19 note and Dr. Bermel's note on August 17? 20 A. The -- the -- where I chart is based on 21 the need to charge -- to produce billing charges, 22 so I simply write my note on whichever more 23 detailed note there is, which by the way, now that 24 I think about it, Dr. Bermel 's note is dated 20 -- is 25 timed at 2200, 10:00 p.m. 0053 1 Q. Yes. 2 A. And in that note, he writes, "Taken for 3 emergency CTA/CTP which showed early infarct 4 signs." So, in fact, Dr. Bermel noted at 10 p.m. 5 the CT findings, not 11:15 p.m. And that confirms 6 what I told you earlier that our residents quickly 7 go with the patient to CAT scan and will -- will call 8 us with -- with the -- their preliminary results. 9 Q. Okay. Let's look at Bermel Exhibit 3. 10 It's a two-page note from the EP staff. Tell me 11 when you have that. 12 A. I have it. 13 Q. At the bottom, it says, "From EP 14 standpoint patient with no cardiac diagnosis, there 15 is no contraindication to any aggressive 16 neurotreatments deemed necessary at this time 17 including anti-coagulation and thrombolysis." 18 And my question for you is: Is that different 19 in any respect from the way you evaluated this 20 patient for IV thrombolytics? 21 MS. CARULAS: Objection. 22 A. Could you re -- could you rephrase that? 23 BY MR. KULWICKI: 24 Q. Sure. I think you indicated earlier that 25 the fact of the patient's prior surgery was a 0054 1 contraindication to or a consideration weighing 2 against the administration of TPA, IV TPA. My 3 question is: Does this seem to differ from that 4 conclusion that the surgery was a factor weighing 5 against that treatment? 6 A. Obviously, it differs. But that's her 7 opinion. She's not a stroke neurologist. 8 Q. If you had known this at the time that you 9 were evaluating this patient for IV TPA, would it 10 have changed your evaluation in any respect? 11 MS. CARULAS: Objection. 12 A. My evaluation, no. My evaluation would 13 have been the same. 14 BY MR. KULWICKI: 15 Q. And by "evaluation," I mean your 16 conclusion that the patient was not a candidate for 17 TPA? 18 A. No. 19 Q. It -- no, it -- no, it wouldn't have changed 20 that conclusion? 21 A. It would -- it would not have. 22 Q. Okay. Thanks for clarifying. 23 Doctor, do you have an opinion as to what 24 caused this patient's stroke? 25 A. A -- a central embolic source. 0055 1 Q. And what does that mean? 2 A. A blood clot that came somewhere 3 upstream of the right carotid artery. So the aorta, 4 the -- the heart, the -- the right vent -- the left 5 ventricle, the left atrium. 6 Q. And do you have any more specific 7 explanation for why the patient had a stroke other 8 than that? 9 A. Well, he had -- he had two risk factors. 10 He has atrial fibrillation and he had just undergone 11 an oblation therapy. 12 Q. Based on imaging or clinical evaluation, 13 can you characterize the size of the thrombus or 14 the clot in his middle cerebral artery? 15 A. No. 16 Q. Would you agree that it was very large? 17 A. Probably, yes. And -- and you -- you said 18 middle cerebral artery. His thrombus and 19 occlusion were in fact in the carotid terminus. 20 Q. Okay. In terms of risk factors, would a 21 precipitous decline in the patient's ACT due to 22 protamine reversal increase the risk of this type of 23 clot? 24 MS. CARULAS: Objection. 25 A. I -- I -- I don't know. I think that would 0056 1 be conjecture. 2 BY MR. KULWICKI: 3 Q. With respect to recent catheter oblation 4 being a -- a risk factor for stroke, can you tell me 5 how common it was for you to see patients after an 6 oblation procedure with a stroke? 7 MS. CARULAS: Objection. 8 THE WITNESS: Should I answer? 9 MS. CARULAS: If you -- I mean, if you 10 recall or know the statistics. 11 A. It's exceedingly uncommon. In fact, this 12 may be the only one that I recall. 13 BY MR. KULWICKI: 14 Q. Doctor, is severe headache a sign or can 15 it be a sign or symptom of a stroke? 16 A. It can be. 17 Q. Are patients with elevated homocysteine 18 levels at an increased risk of stroke? 19 A. Yes. 20 Q. Are patients who have a normal 21 homocysteine level at an increased risk of stroke? 22 A. Relative to what? 23 Q. General population. 24 A. If they -- if they have -- could -- could 25 you -- that's a pretty general question. 0057 1 Q. Yeah. Let me re-ask it. If a patient has 2 a normal homocysteine level, are they considered 3 to be at increased risk of stroke? 4 A. Without any other factors, the answer 5 would be "no." 6 Q. Is there any evidence in the record that 7 Mr. Sullivan had an increased homocysetine level 8 or elevated homocysteine level at the time of this 9 stroke? 10 A. Nothing in our -- let me look carefully, 11 but none -- none of the neurology stroke notes 12 written that evening have that data. So that's all I 13 can comment on. 14 Q. Okay. In terms of patients who've had a 15 recent catheter oblation be at an increased risk of 16 stroke, what is it about that procedure that 17 increases the risk of stroke? 18 MS. CARULAS: Note an objection. But 19 go ahead. 20 A. Okay. Pre -- presumably, the oblation 21 which results in a scar of the heart just like a 22 heart attack causes a -- a thrombus to form, and 23 that thrombus can then embolize. 24 BY MR. KULWICKI: 25 Q. And would you agree that the risk of 0058 1 stroke from an oblation procedure would be 2 increased by the number of individual oblations 3 that are performed within the heart? 4 MS. CARULAS: Objection. 5 A. That -- that is not my area of research, 6 so I can't answer that. 7 BY MR. KULWICKI: 8 Q. Would you agree that the amount of time 9 that an energy delivering instrument is in the 10 heart -- in the heart delivering energy for purposes 11 of oblation that that time factor can increase the 12 risk of stroke? 13 MS. CARULAS: Objection. 14 A. Again, I don't know. 15 BY MR. KULWICKI: 16 Q. Fair enough. With respect to Exhibit 2, 17 the first item on there is a cardiology note, Doctor, 18 and I think you told me that you thought that was 19 from a cardiology fellow or resident. And how did 20 you make that determination that that's who that 21 was as opposed to a cardiology attending? 22 A. Because it says "Cardiology cross-cover," 23 and generally that's a resident or fellow on call. 24 Q. What does that term mean, "cross-cover"? 25 A. It means that they're on call covering 0059 1 multiple services. So -- well, more specifically, it 2 means that they are not the individual primarily 3 responsible for the care of that patient. They're 4 not the admitting physician or admitting service. 5 They're just covering for the night. 6 Q. And in terms of "cross-cover," does that 7 mean that it could be a -- a more junior resident 8 who is covering various services, including 9 cardiology and possibly other internal medicine 10 type services? 11 MS. CARULAS: Objection. 12 A. Well, but I know that that's not the case 13 at the Cleveland Clinic, that the cardiology fellows 14 were the ones primarily on call. 15 BY MR. KULWICKI: 16 Q. Okay. Doctor, we have been at this for 17 about an hour and a half. Do you feel like I've -- 18 you've heard all my questions? 19 A. I have. 20 Q. Do you feel like you've understood me, 21 given the telecommunication? 22 A. Yes. 23 Q. And have I given you ample opportunity to 24 answer the questions and explain yourself? 25 A. Yes. 0060 1 Q. Okay. There is a CT scan that was 2 performed on August 19 at 11:06 a.m., and it 3 states that it's compared with the August 17 CT 4 scan that was taken in the immediate post-stroke 5 period. 6 It states, [reads] Integral development -- 7 and -- and this is under the impression. It states, 8 [reads] Integral development of an acute bland 9 right ACA/MCA/ICA infarct. Can you tell me what 10 that means? 11 A. That there's a stroke in the anterior 12 cerebral artery territory on the right. 13 Q. And does it appear, based on this 14 interpretation of the August 19 CT scan that the 15 stroke worsened between August 17 and August 16 19? 17 A. I'm not sure what you mean by the word 18 "worsened." 19 Q. That more of the brain was involved. 20 A. Well, that -- that region of brain was 21 involved on the initial scan. 22 Q. I'm sorry. You cut out. We've been doing 23 great. I've been hearing you very well -- 24 A. Yeah. 25 Q. -- until that last -- 0061 1 A. Okay. 2 Q. -- answer. Could -- could you try that 3 again? 4 A. So I said I disagree. That portion of the 5 brain was, in fact, in -- seemed to be involved on 6 that very initial CT perfusion scan. 7 MR. KULWICKI: Okay. All right. Thank 8 you. And, Doctor, that's all the questions I have. 9 Thank you -- yeah, thank you for your time and 10 your patience with me. 11 [WHEREUPON, the Telephonic Deposition of 12 Alex Abou-Chebl, M.D. concludes at 11:05 a.m.] 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0062 1 C A P T I O N 2 The Telephonic Deposition of Alex 3 Abou-Chebl, M.D., taken in the matter, on the 4 date, and at the time and place set out on the title 5 page hereof. 6 It was requested that the deposition be 7 taken by the reporter and that same be reduced to 8 typewritten form. 9 It was agreed by and between counsel 10 and the parties that the Deponent will read and 11 sign the transcript of said deposition. 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19 . 20 . 21 . 22 . 23 . 24 . 25 . 0063 1 C E R T I F I C A T E 2 STATE OF_____________________________: 3 COUNTY/CITY OF__________________________: 4 Before me, this day, personally appeared 5 Alex Abou-Chebl, M.D., who, being duly sworn, 6 states that the foregoing transcript of his/her 7 Deposition, taken in the matter, on the date, and 8 at the time and place set out on the title page 9 hereof, constitutes a true and accurate transcript 10 of said deposition. 11 ________________________________________ 12 Alex Abou-Chebl, M.D. 13 14 SUBSCRIBED and SWORN to before me this 15 _____________day of______________________, 16 2010, in the jurisdiction aforesaid. 17 . 18 . 19 _______________ ____________________ 20 My Commission Expires Notary Public 21 . 22 . 23 . 24 . 25 . 0064 1 DEPOSITION ERRATA SHEET 2 . 3 RE: Court Reporting Services, Inc. 4 FILE NO.: 19311 5 CASE CAPTION: Shannon Sullivan, et al. v. The 6 Cleveland Clinic Foundation 7 8 DEPONENT: Alex Abou-Chebl, M.D. 9 DEPOSITION DATE: April 7, 2010 10 . 11 To the Reporter: 12 I have read the entire transcript of my Deposition 13 taken in the captioned matter or the same has 14 been read to me. I request that the following 15 changes be entered upon the record for the 16 reasons indicated. I have signed my name to the 17 Errata Sheet and the appropriate Certificate and 18 authorize you to attach both to the original 19 transcript. 20 . 21 ___________________________________________ 22 ___________________________________________ 23 ___________________________________________ 24 ___________________________________________ 25 ___________________________________________ 0065 1 ___________________________________________ 2 ___________________________________________ 3 ___________________________________________ 4 ___________________________________________ 5 ___________________________________________ 6 ___________________________________________ 7 ___________________________________________ 8 ___________________________________________ 9 ___________________________________________ 10 ___________________________________________ 11 ___________________________________________ 12 ___________________________________________ 13 ___________________________________________ 14 ___________________________________________ 15 ___________________________________________ 16 ___________________________________________ 17 ___________________________________________ 18 ___________________________________________ 19 ___________________________________________ 20 ___________________________________________ 21 ___________________________________________ 22 ___________________________________________ 23 . 24 SIGNATURE:____________________DATE:______ 25 . 0066 1 CERTIFICATE OF REPORTER 2 STATE OF KENTUCKY AT LARGE: 3 I, CAROLA G. STRIJEK, Notary Public for 4 the State of Kentucky at Large, do hereby certify 5 that the foregoing was reported by stenographic 6 and mechanical means, which matter was held on 7 the date, and at the time and place set out in the 8 caption hereof and that the foregoing constitutes a 9 true and accurate transcript of same. 10 I further certify that I am not related to any of 11 the parties, nor am I an employee of or related to 12 any of the attorneys representing the parties, and 13 I have no financial interest in the outcome of this 14 matter. 15 GIVEN under my hand and Notarial seal this 16 _______ day of __________________, 2010. 17 . 18 My Commission Expires: Notary Public 19 . 20 SEPTEMBER 27, 2012 ____________________. 21 . 22 . 23 . 24 . 25 .