0001
 1             IN THE COURT OF COMMON PLEAS
 2                OF SUMMIT COUNTY, OHIO
 3                 ~~~~~~~~~~~~~~~~~~~~
 4   CHARLES DeLOREAN, etc.,
 5   
 6               Plaintiff,
 7   
 8         vs.            Case No. 2009-05-3844
 9   
10   COPLEY HEALTH CENTER, et al.,
11   
12               Defendants.
13                 ~~~~~~~~~~~~~~~~~~~~
14                    Deposition of
15               KEITH B. ARMITAGE, M.D.
16   
                    December 14, 2010
17                      3:00 p.m.
18                      Taken at:
             Rennillo Deposition & Discovery
19                  100 Erieview Tower
20                1301 East Ninth Street
21                   Cleveland, Ohio
22   
23   
24   
25                Cynthia Sullivan, RPR
0002
 1   APPEARANCES:
 2   
 3         On behalf of the Plaintiff:
 4               Mishkind Law Firm Co., by
 5               DAVID A. KULWICKI, ESQ.
 6               Skylight Office Tower, Suite 660
 7               1660 West Second Street
 8               Cleveland, Ohio  44113
 9               (216) 241-2600
10               dkulwicki@mishkindlaw.com
11   
12         On behalf of the Defendants:
13               Reminger Co., by
14               STEPHAN C. KREMER, ESQ.
15               200 Courtyard Square
16               80 South Summit Street
17               Akron, Ohio  44308
18               (330) 375-1311
19               skremer@reminger.com
20                      ~ ~ ~ ~ ~
21   
22   
23   
24   
25   
0003
 1                   TRANSCRIPT INDEX
 2   
 3   APPEARANCES...............................    2
 4   
 5   INDEX OF EXHIBITS ........................    4
 6   
 7   EXAMINATION OF RAYMOND W. ROZMAN, JR., M.D.:
 8   BY MR. KULWICKI...........................    5
 9   
10   REPORTER'S CERTIFICATE....................   53
11   
12   EXHIBIT CUSTODY
13   EXHIBITS RETAINED BY COURT REPORTER
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0004
 1                  INDEX OF EXHIBITS
 2   NUMBER           DESCRIPTION             MARKED
 3   Exhibit 1   An August 3 Letter............   7
 4   Exhibit 2   A Curriculum Vitae............   8
 5   
 6   
 7   
 8   
 9   
10   
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0005
 1         KEITH B. ARMITAGE, M.D., of lawful age,
 2   called for examination, as provided by the Ohio
 3   Rules of Civil Procedure, being by me first
 4   duly sworn, as hereinafter certified, deposed
 5   and said as follows:
 6        EXAMINATION OF KEITH B. ARMITAGE, M.D.
 7   BY MR. KULWICKI:
 8         Q.    Doctor, kindly state your name and
 9   spell your last name for the record.
10         A.    Keith B. Armitage, A-R-M-I-T-A-G-E.
11         Q.    Doctor, we're here to take your
12   deposition in the matter of Charles DeLorean,
13   Executor of the Estate of Shirley DeLorean,
14   versus Copley Health Center.  I understand
15   you've been retained by Dr. Girard's counsel to
16   look into this matter, true?
17         A.    Correct.
18         Q.    Have you prepared any report based
19   on your findings, the findings from your
20   review?
21         A.    No.
22         Q.    In terms of the materials that you
23   reviewed, there is a letter here dated
24   August 3, 2010, from defense counsel,
25   Mr. Kremer, and it lists ten or so things.
0006
 1   Would that be the full list of things that
 2   you've reviewed in this matter?
 3         A.    No.  I've reviewed what's on that
 4   page, and then since then I think I was sent
 5   the depositions of the daughter and the husband
 6   and then of two plaintiff's experts and one
 7   defense expert.
 8         Q.    Was the defense expert, was it
 9   Dr. Rozman or Dr. Newman?
10         A.    Dr. Newman.
11         Q.    Do you know both Drs. Newman and
12   Rozman?
13         A.    I know Dr. Rozman.  He was a
14   resident a couple years ahead of me back in the
15   day.  There was a period of time in the early
16   '90s when we would send residents over to the
17   clinic for outpatient rotations, and Dr. Newman
18   was very interested in education.  I spoke to
19   her on the phone a couple times more than ten
20   years ago.  I don't think I've ever met her.
21         Q.    There are a number of other
22   physicians involved in this matter as treating
23   physicians, and I'll just list a few:
24   Dr. Girard, Dr. Clavecilla, Dr. Ford,
25   Dr. Miller, Dr. Chandukar, Dr. Simon.  Do you
0007
 1   know any of those physicians by chance?
 2         A.    I don't.
 3         Q.    Plaintiff's expert is a doctor by
 4   the name of Ciaran Kelly at Harvard Medical
 5   School.  Do you know Dr. Kelly either
 6   professionally or through his literature?
 7         A.    Just through this case.
 8         Q.    Then there is another plaintiff's
 9   expert by the name of Erik Dubberke who has not
10   been deposed, and we actually withdrew him.  Do
11   you know Dr. Dubberke by any chance?
12         A.    I don't.
13         Q.    Did you do any research in
14   preparation for today's deposition?
15         A.    I did not, not specifically for
16   this case.  I've written a few chapters on
17   C. diff and I've given a lot of lectures on
18   C. diff, so I have a lot of articles, but
19   nothing specific to this case.
20         Q.    With regard to your chapters on
21   C. diff, can you just identify what those are?
22   We'll mark your CV as Exhibit 2.  We'll mark
23   the August 3 letter as Exhibit 1.
24                    -  -  -  -  -
25               (Thereupon, Deposition Exhibit 1, an
0008
 1               August 3 Letter, was marked for
 2               purposes of identification.)
 3                    -  -  -  -  -
 4                    -  -  -  -  -
 5               (Thereupon, Deposition Exhibit 2, a
 6               Curriculum Vitae, was marked for
 7               purposes of identification.)
 8                    -  -  -  -  -
 9               MR. KREMER:  I'm sorry, Dave, what
10   was Exhibit 1?
11               MR. KULWICKI:  One is the August 3
12   letter.  Exhibit 2 is the CV.
13               MR. KREMER:  I think that might be
14   multiple letters.
15               MR. KULWICKI:  Yes.  I'm just going
16   to mark the August 3.
17               MR. KREMER:  You're not marking the
18   rest of them?
19               MR. KULWICKI:  No, I'm not.
20         A.    I marked three chapters having to
21   do with gastroenteritis.  I know in this one I
22   did a lot of writing on C. diff.
23         Q.    Is that numbered in any way?  It's
24   the first one on page what?
25         A.    I'll number them one, two, three.
0009
 1   Number two was the one that had the most about
 2   C. diff.
 3         Q.    In terms of those chapters, are
 4   they all devoted exclusively to C. diff, or
 5   they just cover the topic?
 6         A.    The number two, probably a third of
 7   the chapter was on C. diff.  The other two just
 8   covered the topic, I believe.  I'm only
 9   positive that number two had a lot about
10   C. diff.
11         Q.    In your practice do you endorse the
12   concept of the empiric use of antibiotics to
13   treat C. diff under appropriate circumstances?
14         A.    I do, but I think the paradigm is
15   changing, and the changing paradigm is
16   primarily related to what is called -- what we
17   call the epidemic strain.  I think previously
18   people would have a patient they suspected who
19   had C. diff test for the presence of C. diff
20   and treat it as positive.
21               Most of my time is in an acute care
22   setting, and in that setting if we have a
23   reasonably strong suspicion, we treat before
24   the test comes back.  If we have a mild
25   suspicion, we don't.  I guess if you have
0010
 1   moderate suspicion, it's variable, but if there
 2   is a strong suspicion in an acute care setting.
 3               But I think that approach is
 4   evolving, and I think that infectious disease
 5   and GI doctors are probably more aware that
 6   that's an evolving issue than nonspecialists.
 7         Q.    In terms of the evolution of that
 8   standard of care that you just described, is it
 9   your testimony or will it be your testimony at
10   trial that it was different back in -- I can't
11   remember when this case arose.
12         A.    2007, I think.
13         Q.    Was it different in 2007 than it is
14   today?
15         A.    Yeah.  I think there is a lot of --
16   I mean, I've been asked in depositions how I
17   define the standard of care, and I guess it's
18   what a reasonably prudent, qualified physician
19   would do under similar circumstances.
20               As someone who has a real interest
21   in C. diff and reads a lot about it and works
22   in an acute care setting versus the community
23   and where we talk about it a lot and we have
24   people at Case Western who I work with who did
25   research on it, I think it's clear, you know,
0011
 1   for someone with my background I would expect
 2   that approach.
 3               I think even now among community
 4   doctors this paradigm shift hasn't made it all
 5   the way out to every community doctor and
 6   certainly not in 2007.
 7         Q.    Would you agree with the notion
 8   that doctors that are in a setting where the
 9   risk for C. diff is highest ought to be
10   particularly aware of the signs, symptoms, and
11   treatment of the condition?
12               MR. KREMER:  Objection.  Go ahead
13   and answer.
14         A.    Well, I think that infectious
15   disease doctors in this acute care setting
16   certainly have that awareness, and my
17   observation is that doctors who have been
18   practicing a while in nursing homes don't see
19   that much C. diff and are not attuned to
20   C. diff issues the same way doctors who are in
21   the acute care setting are.
22         Q.    In terms of Copley Health Center,
23   you used the term nursing home.  Is it an
24   appropriate description of that facility as a
25   nursing home?
0012
 1         A.    Yeah.  You could call it a skilled
 2   nursing home, nursing home rehab facility.  Any
 3   of those would work, yeah.
 4         Q.    Have you done any primary care work
 5   in a nursing home setting or in consultation
 6   like Dr. Girard was with patients who are in a
 7   nursing home setting yourself?
 8         A.    I have.
 9         Q.    Tell me what nursing homes.
10         A.    Not a ton.  As you know, I work at
11   University Hospital, and we have a SNF on our
12   campus.
13               There was a period of time in the
14   mid '90s when they lacked physicians to cover
15   those patients, and there was a colleague of
16   mine who was -- there was two of us in the
17   department of medicine who were asked by our
18   chairman, you know, for, you know, additional
19   compensation if we would do additional work and
20   take care of patients in Hanna House, patients
21   who didn't have doctors, and I did that for a
22   number of years in the mid '90s.  I certainly
23   haven't done that, that role, for ten years.
24               I do consult in Hanna House quite
25   frequently.  Again, it's a skilled nursing unit
0013
 1   that's adjacent to an acute care hospital, so
 2   consultants are available.
 3               Then I have a couple patients, one
 4   patient right now, in a nursing home.  It's a
 5   complex patient.  The nurses in the nursing
 6   home page me about three times a week about
 7   this patient, and it's kind of a special
 8   patient that I've followed since 1992.  I don't
 9   have a lot of patients in nursing homes.
10         Q.    When you mentioned your
11   consultations with respect to patients in the
12   Hanna House currently, is that where a
13   physician who is primarily caring for the
14   patient would consult with you?
15         A.    That's correct.  Sometimes there is
16   patients that I'll be following either as the
17   primary doctor or as a consultant who go from
18   the acute care to the rehab setting, and then
19   we'll go and see them, and sometimes we get
20   consulted primarily in the skilled nursing
21   setting to go see patients.
22         Q.    In this case will you be offering
23   an opinion regarding the cause of
24   Mrs. DeLorean's death?
25         A.    I will.
0014
 1         Q.    Is it your opinion that her C. diff
 2   infection contributed in any fashion to her
 3   death?
 4         A.    Well, I would answer the question
 5   this way:  I think that she became septic and
 6   had an arrest, and given her age and her risk
 7   factors, her doing poorly after an arrest,
 8   particularly her BMI, she didn't recover from
 9   the arrest.
10               I think the arrest was precipitated
11   by sepsis from candida, and the role of C. diff
12   is unclear.  The association between the
13   C. diff and the candidemia is unclear to me.  I
14   can't exclude an association, but I don't think
15   anybody can say to a reasonable degree of
16   medical certainty there is a direct
17   association.
18         Q.    Do you have an opinion as to
19   whether she acquired the candidemia in -- well,
20   strike that.
21               Do you have an opinion to a
22   reasonable degree of medical probability as to
23   whether she acquired the candida infection in
24   Akron General Medical Center, or did she have
25   it before she was transferred to that hospital?
0015
 1         A.    Well, you know, all human beings
 2   carry candida in their system, but I don't
 3   think it became an infection until she went to
 4   Akron General.
 5         Q.    So do you think more likely than
 6   not she was colonized with candida prior to the
 7   Akron General admission?
 8         A.    Definitely, as are 99 percent of
 9   human beings.
10         Q.    Is that infection a so-called
11   opportunistic infection that tends to become a
12   problem once the host is compromised in some
13   fashion?
14         A.    I think in general that's a true
15   statement, but most commonly you see that in
16   patients who have no neutrophils.  So, for
17   instance, even in AIDS patients, I take care of
18   a lot of AIDS patients in the inpatient
19   setting, and they can be highly
20   immunocompromised and they don't get
21   candidemia, but if you wipe out someone's white
22   cells like with chemotherapy, then that is a
23   common setting.  Most commonly we see
24   candidemia in hospitalized patients with
25   central lines, abdominal surgery, that sort of
0016
 1   thing.
 2               Her case is a bit unique in that
 3   she didn't have classic risk factors for
 4   candidemia.  But if you look at the blood
 5   cultures, she had one around 11:00 a.m. on the
 6   15th, one after 4:00 on the 15th, and they both
 7   grew candida which really implies a persistent
 8   high grade fungal sepsis that, you know, seems
 9   very unlikely that would be a contaminant with
10   these blood cultures drawn five hours apart,
11   and it's an unusual case.
12         Q.    Unusual in what sense?
13         A.    She's not the typical patient that
14   I would see with fungal sepsis.  More typically
15   they are patients who have central lines, been
16   in the hospital for a little bit longer, that
17   have abdominal surgery, diabetics.  But the
18   fact of the matter is she had two blood
19   cultures that grew candida drawn the day that
20   she had that arrest.
21               And the arrest, she didn't have the
22   kind of arrest where you would see someone have
23   a progressive downhill course from C. diff
24   towards an arrest.  She had more of an acute
25   event that's more typical for, you know, a
0017
 1   septic picture, bacteremia or fungemia.
 2         Q.    At the time of her admission to
 3   Akron General when she was diagnosed with a
 4   supraventricular tachycardia, do you attribute
 5   that to her C. diff infection?
 6         A.    I don't think so.
 7         Q.    What do you think was the cause of
 8   that?
 9         A.    I don't know.  I think she had --
10   on the 12th when she went to the emergency room
11   she had C. diff.  I think the CAT scan showed
12   some thickening of the colon.  She didn't have
13   pseudomembranous colitis.  You can actually
14   make a diagnosis of pseudomembranous colitis on
15   a CAT scan.  The findings are pretty
16   pathognomonic.
17               When she was seen in the ER on the
18   12th, her white count was really just minimally
19   elevated, her abdominal exam seemed pretty
20   benign, and on the 12th there was really no
21   evidence of, you know, severe C. diff systemic
22   in terms of the super high white counts you see
23   with C. diff, metabolic acidosis, lack of bowel
24   sounds, concerning abdominal exam.  So it
25   wasn't the kind of acute, more critical
0018
 1   presentation from C. diff that I think would
 2   trigger a cardiac arrhythmia.
 3               Patients, you know, can have SVT
 4   who are completely healthy.  You know, it's a
 5   -- you can just have an area of the heart that
 6   triggers a rapid cycle, and I think she had
 7   narrow complex supraventricular tachycardia,
 8   not clear what triggered it.
 9         Q.    Can sepsis cause an SVT?
10         A.    Sepsis can cause an SVT, and a
11   sinus tach of, you know, 130, 140, 150, 160,
12   170, 180 in a septic patient is extremely
13   concerning, and when its sinus tach from
14   sepsis, that's a very concerning finding.  This
15   was a cardiac arrhythmia and not the type of
16   arrhythmia that you would strongly associate
17   with sepsis like you would sinus tach.
18               You can have a cardiac arrhythmia
19   like that in a variety of settings, and I
20   wouldn't necessarily say it was sepsis.  Again,
21   I don't recall exactly her vital signs.  I'm
22   not sure she met any criteria for sepsis on the
23   13th other than her white count and her pulse.
24   I guess if you attribute her pulse due to
25   infection, then she would meet septic criteria.
0019
 1               But she wasn't -- you know, people
 2   use the word sepsis differently.  She wasn't so
 3   sick on the 12th that the ER doctor gave her
 4   any antibiotics at all.  So if you have someone
 5   that the clinician thinks is septic, they
 6   usually get treated.  People have a pretty low
 7   trigger for giving antibiotics in this day and
 8   age.
 9         Q.    Well, let's make sure that we're on
10   the same page.  I think I actually used sepsis
11   the right way.  Do you define sepsis as meeting
12   the criteria for SIRS due to an infectious
13   cause?
14         A.    Yeah, I do, but that definition
15   comes up most often in these settings.  If you
16   go out to the community, doctors use the term
17   sepsis in three or four different ways.  I try
18   to teach our residents and students what the
19   official definition for sepsis is, but people
20   use it very loosely, particularly people who
21   have been out of training for ten years or
22   more.
23         Q.    In terms of the way you're supposed
24   to use it or the modern definition of sepsis,
25   is it SIRS due to an infectious cause?
0020
 1         A.    Correct.
 2         Q.    In terms of SIRS, it's my
 3   understanding that you meet the criteria for
 4   SIRS if you have two out of the four criteria
 5   for SIRS; is that correct?
 6         A.    That's correct.  We had a couple of
 7   cases of influenza reported in our hospitals.
 8   If you have influenza, you will meet the
 9   criteria for sepsis because it's a pretty broad
10   definition.
11         Q.    Right.  You said that she did not
12   have pseudomembranous colitis.  Tell me why you
13   feel that way.
14         A.    Well, to the best of my
15   recollection, she never had an endoscopy.  I've
16   discussed this many times with our
17   radiologists, that you can see pseudomembranes
18   on a CAT scan.  She had colitis.  There is no
19   doubt she had colitis.  But a CAT scan is a
20   pretty sensitive tool for detecting
21   pseudomembranes, and it's actually a very
22   specific finding; that is, there are not too
23   many things that give you pseudomembranes.
24               I've seen patients where we did a
25   CAT scan because of concerns for whatever
0021
 1   reason where I've gone over the films with the
 2   radiologist, and they said, yeah, this is
 3   pseudomembranes and there ain't anything else
 4   that looks like this.
 5               So there is a spectrum of C. diff,
 6   and colitis is on one part of the spectrum and
 7   pseudomembranous colitis is at another part of
 8   the spectrum, and I don't think there is any
 9   objective evidence that she ever had
10   pseudomembranous colitis although she
11   definitely had colitis.
12         Q.    Did you look at the CAT scan films
13   yourself?
14         A.    I did not.
15         Q.    In a clinical setting, do you
16   typically look at CAT scan films in a patient
17   with suspected C. diff, or do you simply rely
18   on the report of the radiologist?
19         A.    Both.  In our modern hospitals now,
20   they have digital radiology, so especially in a
21   teaching hospital we look at things with the
22   residents.  Typically what I do is in a
23   challenging case I go to radiology and look at
24   it with the radiologist, and I look at CAT
25   scans of the abdomen, but I usually rely on the
0022
 1   radiologist's interpretation.
 2         Q.    The CAT scan in this case, if I
 3   recall correctly, reports that pseudomembranous
 4   colitis is in the radiologist's differential.
 5   Is that your recollection as well?
 6         A.    You know, I don't know if he said
 7   that or not, but if he did, then I think he's
 8   used the terms interchangeably, just colitis
 9   and C. diff.  To me they did not describe
10   pseudomembranes.  Pseudomembranes is a pretty
11   specific finding.
12               Again, I didn't look at the films,
13   I haven't asked a highly regarded radiologist
14   who specializes in CT to look at the films, but
15   I read the description.  To me it sounds like
16   there was a thickened wall of the colon which
17   in my view is not pseudomembranous colitis.
18   Pseudomembranes is very specific and, as I
19   said, a pretty unique finding.
20         Q.    When you say specific and unique,
21   does that mean it's diagnostic for a C. diff
22   infection?
23         A.    When you have a CAT scan and you
24   see pseudomembranes, it's pretty strongly
25   suggestive of C. diff.  So it's not absolutely
0023
 1   diagnostic, but it can be very, very
 2   suggestive.
 3         Q.    We talked about another term
 4   earlier, empiric treatment, and I probably
 5   ought to have you define that just so I make
 6   sure that we're communicating.
 7         A.    I think in general when people use
 8   the term empiric treatment in the infectious
 9   disease world they mean giving an antibiotic
10   before you are sure of the diagnosis or before
11   you're sure of the infecting organism.
12               So in this case, for instance,
13   after her arrest, they did give her broad
14   spectrum antibiotics because they thought she
15   was septic.  There was no specific reason for
16   them to think she had fungal sepsis, and she
17   didn't get any fungal therapy.
18         Q.    In terms of the progression of
19   C. diff, are there certain steps in the
20   progression of untreated C. diff that will put
21   a patient at a worse prognosis as the disease
22   progresses?
23         A.    Can I say one more thing about the
24   CAT scan?
25         Q.    Sure.
0024
 1         A.    The radiologist said diffuse colon
 2   wall thickness may be diverticulitis,
 3   pseudomembranous colitis, or ischemia.  In my
 4   view if you see pseudomembranes, it's not
 5   ischemia and it's not diverticulitis, so I
 6   think the radiologist is just using the term
 7   differently than I do.
 8               Diffuse wall thickening, I've seen
 9   CAT scans of pseudomembranous colitis where you
10   actually see the pseudomembranes separate from
11   the wall anyway.
12               I apologize.  If you can, repeat
13   the question.
14         Q.    That's fine.  No worries.  So
15   ischemic bowel would be a medical emergency;
16   wouldn't it?
17         A.    It can.  It can require -- I mean,
18   typically, you try to reverse the cause of
19   ischemia and get a surgeon involved to see if
20   in their judgment the patient requires removal
21   of that portion.  I mean, not every patient
22   with ischemic bowel needs surgery.  If they
23   have dead bowel, then they definitely do.
24         Q.    If the radiologist can't
25   distinguish between ischemic bowel and
0025
 1   pseudomembranous colitis -- and I forget what
 2   the third potential was.
 3         A.    Diverticulitis.
 4         Q.    Diverticulitis.  What kind of
 5   medical specialist would be better suited at
 6   interpreting that film to try to narrow down
 7   what the actual finding is?
 8         A.    I mean, I think a radiologist is
 9   the one who would describe the film, a
10   radiologist who is experienced and specializes
11   in CT radiography of the abdomen.  But I would
12   -- I'm not sure.  I'm not sure who I would
13   defer to.  I feel like I have expertise in
14   C. diff, and in terms of understanding the
15   context of the findings, I wouldn't defer.
16         Q.    How many C. diff cases have you
17   been involved with personally over your career?
18         A.    I haven't kept track.  I'm sure
19   it's more than 100.  I mean, I had a patient
20   hospitalized last week.  I get a lot of
21   outpatient referrals for C. diff.  C. diff,
22   it's a unique infection in many ways, but one
23   of the things that is most unique about it is
24   its tendency to have multiple relapses, and
25   almost all of those patients get sent to our
0026
 1   clinic.
 2               I think, since I've been at the
 3   hospital so long and I'm well known, I get a
 4   lot of C. diff cases sent to me in the
 5   outpatient setting, and then I see a lot in the
 6   hospital.
 7         Q.    In terms of consultations, is it
 8   appropriate for a primary care physician to
 9   consult a GI physician or an ID doc like
10   yourself interchangeably?  Are either of those
11   specialists competent to treat the condition?
12         A.    See, that is an interesting
13   question.  I think they are.  Again, I'm biased
14   that certainly in our institution I think it's
15   the ID doctors who have a greater academic
16   interest in C. diff, who do research in
17   C. diff, and publish and give grand rounds on
18   C. diff.  There are certainly other
19   institutions where the GI doctors do that.
20               I think, in the environment I work
21   in, typically infectious disease doctors are
22   consulted for management issues on patients
23   with C. diff, and gastroenterologists are
24   typically not consulted for a narrow issue with
25   C. diff unless it's for an endoscopy, but I
0027
 1   know that's not the case in every institution.
 2         Q.    Have you given or prescribed
 3   antibiotics to be given rectally in a patient
 4   with C. diff who is having difficulty keeping
 5   oral antibiotics down?
 6         A.    I've given vancomycin.
 7         Q.    What is the utility of that?
 8         A.    If a patient with C. diff has an
 9   ileus and lacks adequate peristalsis, oral
10   vancomycin may not make it to the colon.  We've
11   treated patients with severe refractory C. diff
12   who just don't seem to be responding to
13   IV Flagyl, PO vancomycin.
14               There is a lot of interest now in
15   therapies in C. diff because, especially with
16   this epidemic strain, there are patients that
17   just don't respond to appropriate therapy.  I
18   had a patient once on IV vancomycin, PO
19   vancomycin, and PR vancomycin for different
20   reasons.  If it came in any other routes, I
21   would have used it.  I haven't used rectal
22   vancomycin too many times.
23         Q.    Have you had any patients undergo
24   surgery for C. diff?
25         A.    I have.
0028
 1         Q.    Tell me under what circumstances
 2   that's indicated.
 3         A.    Patients typically get surgery for
 4   C. diff for toxic megacolon, and there is not a
 5   lot of clear guidelines on when you operate.  I
 6   always tell our residents and students if a
 7   patient would die without an operation, then
 8   you operate.  If they would live without the
 9   operation, you don't do the operation.
10               There are patients who have severe
11   colitis who we bring back with no operation,
12   and there are patients who die of C. diff who
13   perhaps in retrospect, you know, someone might
14   have operated on.  But it's hard to predict
15   which patients are going to need an operation,
16   and ultimately it's a surgeon's judgment issue.
17   But in my practice patients who I think have
18   severe C. diff, we do imaging studies, and if
19   the imaging studies raise concern for toxic
20   megacolon, we consult surgery.
21         Q.    In terms of this epidemic strain,
22   is it your opinion that Mrs. DeLorean had the
23   epidemic strain?
24         A.    It is not.  I don't know which
25   strain she had, but it didn't seem to be
0029
 1   particularly aggressive.
 2         Q.    Do you have an opinion as to
 3   whether or not Dr. Girard's handling of her
 4   involvement with Mrs. DeLorean fell within
 5   accepted standards of care?
 6         A.    I do.
 7         Q.    What is your opinion?
 8         A.    That it did.
 9         Q.    That it?
10         A.    That it did.
11         Q.    Why do you feel that way?
12         A.    Well, I think among doctors who
13   worked in nursing homes certainly in 2007 and,
14   you know, we could argue about 2010, but I
15   think in 2007 the standard of care for
16   suspected C. diff did not require initiation of
17   empiric therapy.
18               It's interesting in this case, I
19   mean, the experts on the plaintiff's side were
20   not critical of Dr. Ford, were not critical of
21   the doctors at Akron General, but they were
22   only critical of Dr. Girard, I'm not sure why,
23   for not starting the C. diff therapy.
24               Number one, in my opinion the
25   standard of care -- again, I feel like in
0030
 1   talking about C. diff, you know, the old saying
 2   is everything looks like -- to a carpenter
 3   everything looks like a nail.  So as an ID
 4   doctor, as someone with an interest in C. diff
 5   where it's a large part of my practice, you
 6   know, I may have a different approach, but
 7   clearly in 2007 the standard of care didn't
 8   require empiric therapy when it was suspected.
 9               I think that Dr. Girard had two
10   choices, either send the patient to the ER or
11   temporize.  I think she relied on the nurses to
12   describe the clinical acuity of the patient,
13   and I think that -- I think Dr. Kelly is a
14   little naive thinking that she was going to go
15   see the patient.  Typically, nursing home
16   doctors rely on the nurses to give them a
17   clinical picture and send them to the ER.
18               I work in an acute care setting.  I
19   get a lot of patients like that who get
20   admitted to me or come to our ER.  I used to
21   work in the ER a little bit.  I guess
22   Dr. Kelly, my recollection was he was mildly
23   critical of the Imodium but didn't think it
24   made a difference, so I guess that's a
25   nonissue.
0031
 1         Q.    Do you agree with that with respect
 2   to the Imodium?
 3         A.    I agree it did not make a
 4   difference.
 5         Q.    Do you in your practice use Imodium
 6   in patients who are suspected of having
 7   C. diff?
 8         A.    In my practice I use Imodium in
 9   patients with C. diff, and there is literature
10   now about that.
11         Q.    In terms of the other caregivers
12   here, are you critical of Dr. Ford in any
13   respect in terms of the standard of care?
14         A.    No.
15         Q.    How about with respect to the
16   nursing staff at Copley Health Center?
17         A.    You know, the nurses, plaintiff's
18   expert seemed to detail a lot of issues with
19   their documentation, and I haven't seen a
20   rebuttal from a defense nursing expert, so I
21   wouldn't give a standard of care opinion.
22   There did seem -- you know, there was issues
23   pointed out from the nurses plaintiff's expert.
24         Q.    In a setting like this, if you were
25   in Dr. Girard's shoes and you got a call about
0032
 1   a patient at a skilled nursing facility who had
 2   diarrhea and the nursing staff related to you
 3   that someone like a Dr. Ford had ordered a
 4   C. diff assay, in a situation like that is
 5   there certain information that you'd want to
 6   know in order to decide whether or not this
 7   patient needed to be transferred to an ER to be
 8   seen or whether to begin empiric therapy or
 9   what action to take?
10         A.    I would expect the nurse to tell me
11   if the patient had abnormal vital signs, and I
12   would ask the nurse how does the patient look?
13   Does she look sick?  I would expect nurses who
14   work in nursing homes to tell you.
15               I think, you know, for the nurses
16   and for the doctor, the easiest thing to do is
17   to send the patient to the ER, but it's not in
18   the patient's best interest to be sent to the
19   ER when they don't need it, so you try to make
20   a judgment call, and I'll leave it at that.
21         Q.    In a patient in a scenario like
22   that, a patient has diarrhea for a day or so
23   and they have ordered a C. diff assay, would
24   you want to get a CBC on that patient to see
25   what the white count looks like?
0033
 1         A.    You know, if I was -- if I thought
 2   the patient needed a CBC, that might be the
 3   patient I would send to the ER if I thought
 4   they were that sick.  Again, it's a little hard
 5   for me to compare what I would do again because
 6   I'm -- I believe I have an interest in C. diff
 7   and talk about it a lot versus a non-infectious
 8   disease doctor.
 9               Typically, in the acute care
10   setting, we get CBCs every day on every
11   patient.  But a CBC can be important when you
12   suspect C. diff in an acute care setting
13   because a white count of over 30,000 is very,
14   very suggestive of C. diff.
15               I'm not critical of Dr. Girard.  I
16   think the patient did get labs.  I forget what
17   date she got labs at Copley.  It was around
18   that time, yeah.
19               MR. KULWICKI:  I forget what I
20   asked.  What was my last question?
21                   (Record read.)
22         A.    It looks like she had labs that
23   day, but not a CBC, and so I'll leave it at
24   that.
25         Q.    What were the labs that were drawn
0034
 1   that day?
 2         A.    It looks like she got a chemistry
 3   profile that was done on Friday, 5-11.  Again,
 4   her BUN was slightly elevated.  Her albumin was
 5   3.3.  Again, severe hypoalbuminemia is
 6   something you see in severe C. diff.
 7         Q.    What is 3.3?
 8         A.    3.3 is slightly low.  It's not
 9   unusual for a hospitalized patient.  It looks
10   like Dr. Ford ordered the lab test.
11         Q.    In terms of the care at Akron
12   General Medical Center during the ER stay, do
13   you have any criticism of any care that was
14   provided there?
15         A.    No, not from a standard of care
16   standpoint.  You know, again, I guess I was
17   surprised that they didn't initiate C. diff
18   therapy earlier once they had the CAT scan that
19   showed colitis.
20         Q.    Let's take it from there.  Any
21   criticism of not starting empiric therapy when
22   the CT scan results were available and the
23   patient was transferred to the floor under the
24   care of Dr. Miller?
25         A.    I would have started C. diff
0035
 1   therapy at that time, and I guess I was
 2   surprised that I think Dr. Kelly was not
 3   critical since he's an expert, he's a
 4   plaintiff's expert critical of Dr. Girard.
 5               I think that, you know, some of it
 6   depends upon what the ER doctor told
 7   Dr. Miller, what the communication was, and I
 8   don't have that information.  I don't have
 9   enough information to give an answer more than
10   that.
11         Q.    Why would you have started it under
12   those circumstances?
13         A.    I think in a patient who is
14   suspected of having C. diff where the CT scan
15   shows colitis, again, as an infectious disease
16   doctor with an interest in C. diff, I would
17   have started C. diff therapy.
18               It's a little hard for me to
19   comment on Dr. Miller as a standard of care
20   issue because I feel like I have, you know, an
21   interest in C. diff and also I think am more
22   aware that the paradigm of treating has changed
23   more towards empiric treatment.
24         Q.    In terms of Dr. Miller's handling
25   of this patient's care, should he have at any
0036
 1   point in time gotten either a GI consult or ID
 2   consult?
 3         A.    It looks like he did get an ID
 4   consult.
 5         Q.    When was that?
 6         A.    It looks like on the 15th.
 7         Q.    How about before that, do you think
 8   he should have consulted with somebody?
 9         A.    No.  I think if the patient has
10   nausea and vomiting and isn't able to take PO,
11   the primary therapeutic modality is IV Flagyl,
12   and I don't think that there were other
13   treatment options that either GI or ID could
14   have come up with at that point on the 13th or
15   the 14th.
16         Q.    Forgive me, is IV Flagyl an
17   appropriate treatment for C. diff?
18         A.    It's a question that I bang my head
19   about all the time.  Metronidazole, Flagyl has
20   almost 100 percent oral viability.  So in my
21   mind whether you give it PO or IV, it's the
22   same drug.  Patients that have severe C. diff
23   or patients that have C. diff with nausea and
24   vomiting, I give them IV Flagyl, and I think it
25   works the same as PO Flagyl.  For the sickest
0037
 1   patients with C. diff, we give oral vancomycin
 2   and IV Flagyl both.
 3         Q.    Would you agree that her age was a
 4   risk factor for a C. diff infection?
 5         A.    Yes.
 6         Q.    Would you agree that her recent use
 7   of clindamycin was a risk factor for C. diff
 8   infection?
 9         A.    It was.  Again, typically we think
10   of C. diff in patients who take longer courses
11   of antibiotics, but she had been -- yeah, so it
12   was.
13         Q.    Isn't clindamycin a particular
14   antibiotic or an antibiotic that is
15   particularly associated with C. diff
16   infections?
17         A.    That's an interesting question
18   because, again, if you ask a physician who was
19   trained more than ten years ago and you say the
20   word clindamycin, the first thing they think of
21   is C. diff.
22               The most recent studies looking at
23   risk factors for C. diff, particularly the
24   epidemic strain, shows that there are several
25   classes of antibiotics that are more often
0038
 1   associated with C. diff, the quinolones and the
 2   cephalosporins, but there is an association
 3   between clindamycin going back to the 1970s
 4   when there weren't that many drugs that
 5   affected the normal flora, and clindamycin was
 6   around then, so clindamycin has been associated
 7   with C. diff.
 8         Q.    How many different antibiotics are
 9   there?
10         A.    I don't know.  You know, there is
11   not enough, let me tell you.  We're running
12   into problems with some bugs.  But there is not
13   that many classes.  I mean, for instance, there
14   is a whole ton of cephalosporins, but it's just
15   one class.  There is a lot of quinolones, but
16   it's just one class.
17         Q.    Can we agree that being in a
18   skilled nurse facility like Copley Health
19   Center is a risk factor for a C. diff
20   infection?
21         A.    Yes.
22         Q.    Besides those three that we
23   mentioned, what other risk factors are there
24   for the illness?
25         A.    Patients who are immunosuppressed
0039
 1   tend to do worse with C. diff, patients with
 2   some kind of immune dysfunction.  I think being
 3   in an acute care setting or a chronic care
 4   setting and being on antibiotics are risk
 5   factors.
 6         Q.    In your experience is there
 7   anything about the odor or consistency of
 8   diarrhea associated with C. diff that makes it
 9   stand out or increases your suspicion for
10   C. diff?
11         A.    I have certainly heard from
12   multiple nurses that there are some patients
13   where there is a characteristic odor and
14   appearance.  I would answer the question this
15   way:  I think there are patients where
16   experienced nurses really identify the
17   appearance and the odor as typical for C. diff.
18   Not every patient with C. diff has that,
19   however.
20         Q.    Understood.  When you are taking a
21   history or talking to a nurse about a patient
22   that they suspect may have C. diff, do you
23   inquire about that, the odor and the
24   consistency?
25         A.    Nurses usually volunteer it.  So,
0040
 1   you know, that usually comes up that way.
 2         Q.    Have you worked in a setting where
 3   the nursing staff didn't have much experience
 4   with C. diff; in other words, there weren't
 5   very many C. diff infections, if any?
 6         A.    You know, again, most of my time is
 7   spent in an acute care hospital.  I don't --
 8   the nursing homes that I'm familiar with that
 9   are not the one located on our hospital campus,
10   I don't know how much experience they have, so
11   I'm not sure.  I don't know.
12         Q.    When you're dealing with a nurse
13   that either isn't experienced with a particular
14   condition or you don't know about their
15   experience level, is that a time where you want
16   to ask more questions or you have a
17   responsibility to ask more questions as the
18   attending physician or consulting physician?
19         A.    I mean, I think you ask questions
20   based upon the clinical presentation.  I think
21   on the appearance of the stool, I think if the
22   nurse doesn't volunteer, it's unlikely they are
23   going to have an opinion.
24         Q.    Do you have an estimate of the
25   number of times that you have been consulted by
0041
 1   the Reminger law firm in medical-legal matters?
 2         A.    I don't.
 3         Q.    Has it been more than 50?
 4         A.    I haven't kept track.  There is a
 5   lot of Remingers around, you know, in Ohio.
 6   There is Remingers in Columbus and Cincinnati
 7   and Akron and Canton and Sandusky and
 8   Cleveland.  It's probably more than ten.  I
 9   wouldn't think it's more than 50, but I don't
10   know.
11         Q.    Have you testified in a C. diff
12   case in the past?
13         A.    I have.
14         Q.    How many times?
15         A.    To the best of my recollection,
16   I've only testified in court in two cases, but
17   maybe three.
18         Q.    Do you remember was it on behalf of
19   the defense or plaintiff?
20         A.    I know I've testified in one
21   plaintiff's case and one or two defense cases.
22         Q.    Do you remember who the plaintiff's
23   lawyer was in the case involving C. diff?
24         A.    I don't.
25         Q.    Do you know where that was?
0042
 1         A.    It was in Maryland.
 2         Q.    Do you remember anything about that
 3   Maryland case in terms of the physicians
 4   involved or the hospital or the counsel that
 5   were involved?
 6         A.    The only thing I remember with that
 7   case is it was an elderly, debilitated patient
 8   who had been in the hospital and who had
 9   diarrhea, and instead of thinking about
10   C. diff, he got more antibiotics, and a week or
11   two later he was admitted to the hospital, so
12   it was a pretty long time course.
13         Q.    I have read that there are a number
14   of different tests for C. diff toxin and that
15   they have varying degrees of --
16         A.    Sensitivity.
17         Q.    -- sensitivity.  Thank you.  They
18   also have varying degrees of how quickly you
19   can turn around the test result.
20         A.    Yes.
21         Q.    In your experience is it typical or
22   is it acceptable, let's say, for it to take a
23   couple of days to get a C. diff test result
24   back in a setting like this?
25         A.    You know, in my entire career I've
0043
 1   never seen a C. diff ordered stat.  It's just
 2   not the kind of test people order stat.  I
 3   think in an acute care setting it can be
 4   difficult to collect the stool.  It requires
 5   cooperation of the patient to a certain extent.
 6   I think in one of the depositions someone
 7   talked about, you know, patients urinating in
 8   the specimen, that sort of thing.
 9               In an acute care setting, once the
10   specimen is sent to the lab, I expect to get a
11   result in 24 hours.
12         Q.    Do you have any criticism of any
13   aspect of how long it took to get the lab
14   result in this particular case?
15         A.    I think it was five days in this
16   case?  The order was written on the 10th and
17   the lab received it on the 14th and I think the
18   result came back on the 15th?  It's in some of
19   the exhibits.
20         Q.    It was the 14th or the 15th.
21               MR. KREMER:  It was on Monday.
22               THE WITNESS:  So Monday was the
23   14th?
24               MR. KREMER:  Correct.
25         A.    It's hard to -- I mean, in the
0044
 1   nursing home environment where you collect it
 2   and send it off, I guess I would have thought
 3   it would have been maybe one day sooner.  But
 4   it wasn't clear to me from the nurses'
 5   depositions why they didn't get it the morning
 6   of the 11th.  I think they collected it on the
 7   afternoon of the 11th.
 8               I wasn't surprised that it wasn't
 9   picked up until the next day.  I think labs
10   that service nursing homes don't have a pickup,
11   and it was a weekend.  You know, I would just
12   factor all that in.
13         Q.    Then the question is, though, do
14   you intend to offer an opinion that either the
15   lab or the nursing staff fell below the
16   accepted standards of care in the manner in
17   which they processed that test order?
18         A.    I have no opinion.
19         Q.    In past cases I have had ER
20   physicians tell me that in a setting like this
21   the primary responsibility of the ER physicians
22   is to determine the acuity of the problem and
23   to make a decision whether to keep the patient
24   in the hospital or to send them home.
25               In this setting would you agree
0045
 1   that that principle was applicable in the sense
 2   that the ER staff obtained a battery of tests,
 3   made a decision to keep the patient within I
 4   think about six hours, transferred the patient
 5   to the floor, and turned over care to an
 6   attending?  Does that seem appropriate to you?
 7               MR. KREMER:  Can I quote you like
 8   that in your ER cases, Dave?
 9               MR. KULWICKI:  Well, it depends.
10               MR. KREMER:  Go ahead.  I'm sorry.
11         A.    I think that's the fundamental
12   responsibility of the ER.  There are clearly
13   cases where the ER needs to initiate therapy;
14   meningitis, pneumonia.  It's a complicated
15   question.  I think one of the fundamental
16   things the ER had to do is make a triage
17   decision, and depending on the clinical
18   situation, they may have some responsibility
19   for initiating therapy.
20         Q.    Do you have any criticism of
21   Mrs. DeLorean or her family for any reason?
22         A.    No.
23         Q.    Would you have been critical of
24   Dr. Girard if she had started empiric treatment
25   for C. diff?
0046
 1         A.    No.
 2         Q.    I assume you wouldn't have been
 3   critical of the ER personnel or Dr. Miller had
 4   they started empiric treatment likewise?
 5         A.    That's correct.
 6         Q.    In terms of the patient's condition
 7   at Copley Health Center before the transfer to
 8   Akron General, can we agree that C. diff should
 9   have been in the differential?
10         A.    Yes.
11         Q.    I think that there was some
12   discussion that the primary consideration in
13   the differential while the patient was at
14   Copley Health Center was a gastroenteritis, a
15   viral gastroenteritis?
16         A.    Well, I think there is three things
17   in a differential in a patient like this, more
18   than three, but viral gastroenteritis is
19   incredibly common, medications cause diarrhea,
20   and then other infections, salmonella,
21   campylobacter can occur, but C. diff would be
22   in the differential.
23         Q.    Is there anything about viral
24   gastroenteritis in terms of risk factors,
25   history, or symptoms?
0047
 1         A.    The biggest thing I teach about
 2   viral gastroenteritis is that it usually
 3   doesn't last more than two or three days.  It
 4   usually doesn't cause high grade fever.
 5               People can retch and have diarrhea
 6   and they can look sick and feel sick with viral
 7   gastroenteritis, but in adults the most common
 8   cause of viral gastroenteritis by far is
 9   norovirus named for Norwalk, Ohio, which is out
10   in that direction, I think.  It's the virus
11   that made Norwalk, Ohio, famous.  We describe
12   it as a self-limited illness.
13               I work with about 100 residents a
14   year in the hospital.  I think in a given year
15   about half of them get norovirus, about one or
16   two of them go to the ER, and about every year
17   one gets admitted for a day or two.  People can
18   look kind of sick.  It's going around right
19   now.  I've had quite a few friends and
20   colleagues that have had it.
21         Q.    Is viral gastroenteritis typically
22   a seasonal illness?
23         A.    It can be both seasonal and
24   sporadic, so it's more common in the winter,
25   but you can see it year round.
0048
 1         Q.    Is it typically associated with an
 2   outbreak in the sense that it's going around,
 3   as you say?
 4         A.    It can be associated with an
 5   outbreak, so it's famous on cruise ships and
 6   football teams, but there is a lot of sporadic
 7   cases.
 8         Q.    You used the term that the patient
 9   looked sick, and let me just ask you how you
10   would describe that.  How does a patient look
11   sick?
12         A.    Well, experienced clinicians,
13   whether they are nurses or doctors, I think,
14   can have some sense of whether a patient is
15   mildly, moderately, or more severely ill just
16   by being at the patient's bedside and looking
17   at them, and experienced nurses can, I think,
18   have a sense based upon their own experience,
19   their own pattern recognition of whether a
20   patient looks sick, and clinical gestalt is
21   another term that people use.
22         Q.    What would be some of the
23   parameters of that appearance?
24         A.    Well, somehow it's just how the
25   patient looks, how they talk to you, how they
0049
 1   communicate to you, so just the way they look
 2   as being at their bedside.  It's one of those
 3   things.  It's hard to put into words.
 4         Q.    Would one aspect of it be their
 5   color?
 6         A.    It can.
 7         Q.    Would another aspect potentially be
 8   their fatigue level?
 9         A.    Fatigue is more of a chronic issue
10   than an acute issue.
11         Q.    With C. diff would one aspect of
12   how sick the patient would be be how
13   debilitated they are by the diarrhea?
14         A.    Diarrhea no matter what it's from
15   can be debilitating, especially in elderly
16   patients.  That's one reason why people have
17   renewed interest in using Imodium in C. diff,
18   because in most patients the morbidity is from
19   the diarrhea, not from the more complicated
20   course.  That's why there was an editorial in
21   the Journal of Clinical Infectious Diseases
22   saying we should really look at this issue, and
23   there is a clinical trial right now going on
24   about Imodium and C. diff.  But no matter what
25   causes the diarrhea, that can cause morbidity.
0050
 1               I think in general in C. diff, you
 2   know, I've seen patients with severe toxic
 3   megacolon who had no stool out, and then you
 4   see patients who have pretty mild cases of
 5   C. diff who have lots of stool.  So there is
 6   not a one-to-one correlation between the amount
 7   and frequency of stool and the severity of
 8   C. diff.
 9               THE WITNESS:  Do you mind if I grab
10   this (indicating)?
11               MR. KULWICKI:  No, go ahead.
12                   (Brief recess.)
13         Q.    Let me just wrap up.  Doctor, I
14   asked you, I believe, about your causation
15   opinions and about your standard of care
16   opinions.  Are there any other opinions that
17   you feel that or that you expect to testify
18   about at trial that we have not covered yet?
19         A.    I don't think so.
20         Q.    Do you have any facts available to
21   you that would suggest that there was an
22   outbreak of any viral gastroenteritis in Copley
23   Health Center or in the Akron area back in
24   whenever this was, May of 2007?
25         A.    I don't.  Again, viral
0051
 1   gastroenteritis is incredibly common, and it
 2   tends to be sporadic.  We had an outbreak at
 3   our VA nursing home a few years ago, but I'm
 4   not familiar with other nursing home outbreaks.
 5               MR. KULWICKI:  That's all the
 6   questions that I have.  Thank you.
 7               MR. KREMER:  We'll read.
 8               (The deposition was concluded.)
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0052
 1   whereupon, counsel was requested to give
 2   instruction regarding the witness's review of
 3   the transcript pursuant to the Civil Rules.
 4   
 5                      SIGNATURE:
 6   It was agreed by and between counsel and the
 7   parties that the Deponent will read and sign
 8   the transcript of said deposition.
 9   
10                 TRANSCRIPT DELIVERY:
11   Counsel was requested to give instruction
12   regarding delivery date of transcript.
13               THE NOTARY:  Mr. Kulwicki, do you
14   need to order this transcript?
15               MR. KULWICKI:  Yes, no rush.
16               THE NOTARY:  Mr. Kremer, do you
17   need a copy?
18               MR. KREMER:  Yes.
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0053
 1                REPORTER'S CERTIFICATE
 2   The State of Ohio,   )
 3                                SS:
 4   County of Cuyahoga.  )
 5   
 6               I, Cynthia Sullivan, RPR, a Notary
 7   Public within and for the State of Ohio, duly
 8   commissioned and qualified, do hereby certify
 9   that the within named witness, KEITH B.
10   ARMITAGE, M.D., was by me first duly sworn to
11   testify the truth, the whole truth and nothing
12   but the truth in the cause aforesaid; that the
13   testimony then given by the above-referenced
14   witness was by me reduced to stenotypy in the
15   presence of said witness; afterwards
16   transcribed, and that the foregoing is a true
17   and correct transcription of the testimony so
18   given by the above-referenced witness.
19               I do further certify that this
20   deposition was taken at the time and place in
21   the foregoing caption specified and was
22   completed without adjournment.
23   
24   
25   
0054
 1               I do further certify that I am not
 2   a relative, counsel or attorney for either
 3   party, or otherwise interested in the event of
 4   this action.
 5               IN WITNESS WHEREOF, I have hereunto
 6   set my hand and affixed my seal of office at
 7   Cleveland, Ohio, on this ________ day of
 8   ___________________, 2010.
 9   
10   
11   
12   
13               ________________________________
14               Cynthia Sullivan, Notary Public
15               within and for the State of Ohio
16   
17   My commission expires October 17, 2011.
18   
19   
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25   
0055
 1                  DEPOSITION REVIEW
                 CERTIFICATION OF WITNESS
 2   
     RE: Charles DeLorean, etc., v. Copley Health
 3   Center, et al.
     DEPONENT:  KEITH B. ARMITAGE, M.D.
 4   COURT REPORTER:  Cynthia Sullivan, RPR,
     Rennillo Deposition & Discovery
 5   
           In accordance with the Rules of Civil
 6   Procedure, I have read the entire transcript of
     my testimony or it has been read to me.
 7   
           I have made no changes to the testimony
 8   as transcribed by the court reporter.
 9   
10   
     Date                  KEITH B. ARMITAGE, M.D.
11   
           Sworn to and subscribed before me, a
12   Notary Public in and for said State and County,
     the referenced witness did personally appear
13   acknowledge that:
14         1.  They have read the transcript;
           2.  They signed the foregoing sworn
15   statement; and
           3.  Their execution of this Statement is
16   of their free act and deed.
17   I have affixed my name and official seal
     this     day of        , 20     .
18   
19   
20   
21   
22                    Notary Public
23   
24   
25                    My Commission Expires:
0056
 1                  DEPOSITION REVIEW
            ERRATA & CERTIFICATION OF WITNESS
 2   
     RE: Charles DeLorean, etc., v. Copley Health
 3   Center, et al.
     DEPONENT:  KEITH B. ARMITAGE, M.D.
 4   COURT REPORTER:  Cynthia Sullivan, RPR,
     Rennillo Deposition & Discovery
 5   
           In accordance with the Rules of Civil
 6   Procedure, I have read the entire transcript of
     my testimony or it has been read to me.
 7   
           I have listed my changes on the attached
 8   Errata Sheet, listing page and line numbers as
     well as the reason(s) for the change(s).
 9   
           I request that these changes be entered
10   as part of the record of my testimony.
11         I have executed the Errata Sheet, as well
     as this Certificate, and request and authorize
12   that both be appended to the transcript of my
     testimony and be incorporated therein.
13   
14   Date                         Witness
15         Sworn to and subscribed before me, a
     Notary Public in and for said State and County,
16   the referenced witness did personally appear
     and acknowledge that:
17   
           1.  They have read the transcript;
18         2.  They have listed all of their
     corrections in the appended Errata Sheet;
19         3.  They signed the foregoing sworn
     statement; and
20         4.  Their Errata and execution of this
     Statement is of their free act and deed.
21   
     I have affixed my name and official seal
22   this           day of           , 20       .
23   
                      Notary Public
24   
25                    My Commission Expires: