0001 1 IN THE COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO 2 - - - - - 3 4 Shannon Sullivan, et al., ) Judge Brendan J. ) Sheehan 5 Plaintiffs, ) ) 6 vs. ) Case No. ) CV-09-697617 7 Cleveland Clinic ) Foundation, ) 8 ) Defendant. ) 9 - - - - - 10 11 Deposition of: 12 ROBERT BERMEL, M.D. 13 14 April 1, 2010 15 10:00 a.m. 16 17 Location: Cleveland Clinic Foundation 18 9500 Euclid Avenue Cleveland, Ohio 19 20 21 Reporter: Nayann B. Pazyniak, RPR, CRR 22 23 24 25 0002 1 APPEARANCES: 2 3 On behalf of the Plaintiffs: DAVID A. KULWICKI, ESQ. 4 Becker & Mishkind Co., LPA Skylight Office Tower 5 1660 West Second Street, Suite 660 Cleveland, OH 44113 6 216.241.2600 dkulwicki@beckermishkind 7 8 On behalf of the Defendant: 9 ANNA CARULAS, ESQ. Roetzel & Andress, LPA 10 1375 East Ninth Street Cleveland, OH 44114 11 216.623.0150 acarulas@ralaw.com 12 - - - - - 13 14 15 16 17 18 19 20 21 22 23 24 25 0003 1 I N D E X 2 EXAMINATION OF ROBERT BERMEL, M.D. 3 Page Line 4 BY MR. KULWICKI...................4 6 5 6 7 EXHIBITS MARKED 8 Deposition Exhibit 1 .............5 11 9 Deposition Exhibit 2 .............8 1 Deposition Exhibit 3 .............31 18 10 Deposition Exhibit 4 .............41 13 Deposition Exhibit 5 .............45 3 11 Deposition Exhibit 6 .............46 13 12 (Mr. Kulwicki retained possession of exhibits.) 13 - - - - - 14 15 16 17 18 19 20 21 22 23 24 25 0004 1 ROBERT BERMEL, M.D., of lawful age, 2 called for examination, being by me first duly 3 sworn, as hereinafter certified, deposed and said 4 as follows: 5 EXAMINATION OF ROBERT BERMEL, M.D. 6 BY MR. KULWICKI: 7 Q. Okay. Doctor, kindly state your full 8 name and spell your last name for us. 9 A. Robert Bermel, B-E-R-M-E-L. 10 Q. Doctor, my name is Dave Kulwicki, I 11 represent the Sullivans in a lawsuit that was 12 brought against the Cleveland Clinic 13 approximately a year ago. I'm here to take your 14 deposition. I will ask you questions, you will 15 answer verbally, if you will, as opposed to an 16 uh-huh or nuh-uh or a nod of your head so that 17 our court reporter can take down your response 18 accurately. 19 If I ask you a question and you don't 20 understand it, tell me that and I'll restate it 21 to your satisfaction so you understand what I'm 22 asking. Okay? 23 A. Yes. 24 Q. And you are doing great so far waiting 25 for me to finish my question. Sometimes I may 0005 1 stumble around a little bit trying to find the 2 right word, so just be patient with me and take 3 your time in answering. Okay? 4 A. I'll do my best. 5 Q. Thank you. Are you currently employed 6 by the Cleveland Clinic? 7 A. Yes. 8 Q. And I'm going to hand you what I'll mark 9 as exhibit 1. This is a five page CV. Is that 10 your current CV? 11 (Deposition Exhibit 1 was marked for 12 purposes of identification.) 13 A. (Reading.) Yes. 14 Q. Tell me, are you board certified in any 15 specialties of medicine? 16 A. I'm board certified in neurology. 17 Q. And I understand you practice here at 18 the Mellen Center; is that correct? 19 A. That's correct, I practice at the Mellen 20 Center for multiple sclerosis. 21 Q. Is that an interest of yours, MS? 22 A. MS is the specialty of neurology that I 23 chose to pursue a career. 24 Q. I'm here to ask you about events that 25 happened back in August of 06. At the time, it 0006 1 appears that you were in your neurology 2 residency, is that right, or were you in your 3 fellowship by then? 4 A. I was a neurology resident. 5 Q. What year of your residency were you 6 then? 7 A. I would have to refer back to the dates. 8 I know I functioned as a senior neurology 9 resident at that time. It would depend on which 10 month of 2006 it was. 11 Q. I think it was August of 2006. 12 A. I would have just been starting the 13 final year of my residency. 14 Q. And how many year residency is the 15 neurology residency? 16 A. It's a four-year residency. 17 Q. In preparation for today's deposition, 18 did you go through Mr. Sullivan's chart and 19 refresh your recollection as to your care of this 20 patient? 21 A. I had the opportunity to review the 22 portion of the patient's care that I was involved 23 with. 24 Q. Okay. 25 A. So I reviewed my notes pertaining to his 0007 1 care. 2 Q. All right. I think what I would like to 3 do first if we can, and perhaps you are not the 4 right person to do that, and if you are not, just 5 tell me that, and if it's possible, we'll do 6 that, but what I was trying to do is clarify or 7 create a chronology of events in terms of Mr. 8 Sullivan's stroke, in terms of when it was first 9 recognized, when different people got involved in 10 his care and the like. 11 I have prepared a document that I'm 12 calling an acute stroke chronology, and maybe I 13 can just run through it with you and verify that 14 these are, in fact, the times and events as they 15 occurred. 16 A. Could I have a copy of my medical record 17 note then to refer to, because my knowledge of 18 this case is, unfortunately, limited to what I 19 wrote down. 20 Q. Not a problem. Let me mark this as 21 exhibit 2, and this is a seven-page document. 22 This is a seven-page document which is a portion 23 of the progress notes, the handwritten progress 24 notes from this admission. Is your note in 25 there? 0008 1 (Deposition Exhibit 2 was marked for 2 purposes of identification.) 3 A. My note is contained within that, yes. 4 Q. Okay. 5 A. It consists of one page of that seven 6 pages. 7 Q. Okay. And would that be the note on 8 August 17th at 22:00 hours? 9 A. That's the date and time on my note. 10 Q. In reviewing the records, it appeared to 11 me that the first signs of the stroke were 12 recognized on August 17 around 21:00 hours. Are 13 you able to confirm that? 14 A. I'm not able to confirm that exact time. 15 What I can tell you is that if neurology team was 16 not previously involved in the care of this 17 patient prior to 21:15 on that evening, at which 18 point someone, I didn't note who, activated the 19 acute stroke system in the hospital, at which 20 point we were notified that there could be a 21 potential emergency neurological problem with the 22 patient. 23 When responding to a stroke, the other, 24 most-pertinent time is not the time that the 25 patient was found, but the time at which the 0009 1 patient was found last normal neurologically, and 2 that time I have at 20:30. 3 Q. Great. Thank you. And tell me why the 4 time that the patient was last normal is 5 important for your purposes as part of the stroke 6 team? 7 A. We're trying to time the onset of a 8 stroke. I should note that I was part of the 9 stroke team at that point, due to my duties on 10 call, but I no longer have stroke, acute stroke 11 duties in the hospital. 12 To the best of my recollection about my 13 duties at that time, the most-important thing is 14 to time the onset of the stroke to gauge whether 15 or not interventions would be possible. 16 Q. Let me ask you about back in that time 17 frame of August of 06, what was the accepted 18 window of use of tPA as an intervention for 19 stroke? Was it three hours or six hours back 20 then as you recall? 21 MS. CARULAS: I'll just note an 22 objection, but go ahead if you remember. 23 A. Well, this was a relatively standard 24 window of three hours at that point in time. But 25 I should mention that, you mention the name of a 0010 1 medication which is intravenous tissue 2 plasminogen activator or tPA. I assume that you 3 mean that given by vein, IV. 4 Q. Right. Right. Yes. 5 Let me talk to you a little bit about 6 the stroke team and then we'll go through your 7 note. The term, numeric 2 clot, is that a 8 reference to a stroke team? 9 A. That's the actual mnemonic for the pager 10 number in the hospital, so that the nurses and 11 other first activators potentially can remember 12 to call to page the number 2 clot, whatever, when 13 you punch the numbers in on the phone, 2 clot 14 turns out to be. So that's the beeper that is 15 carried by the senior neurology resident in the 16 hospital. 17 Q. Okay. If you recall back in August of 18 06, was there a full-time neurology attending on 19 premises at the Clinic at all times? 20 A. As best I can recall, that was not the 21 case. 22 Q. All right. In terms of the clot team or 23 the stroke team, would there just be a designated 24 senior neurology resident who was primarily 25 responsible for responding to those pages? 0011 1 A. The procedure is that the pager is 2 carried by a senior neurology resident, who then 3 returns a phone call to whatever location it's 4 called from, and then usually breaks with 5 whatever they're doing and runs to the case, if 6 it, you know, was a valid page. 7 Q. Okay. And in August of 2006, was there 8 more than one stroke team at the Clinic? 9 A. To the best of my knowledge, there would 10 only be one team which would be responsible for 11 responding to phone calls to this pager on that 12 night. 13 Q. In terms of your recording the patient 14 last being normal at 20:30, was that based on a 15 review of nurses notes or history taken from the 16 patient or some other source? 17 A. In my note I noted that the patient was 18 last normal at 20:30 during a nursing assessment. 19 So I don't know how I substantiated that, but at 20 the time, that was the best that I could arrive 21 at the patient's last normal. 22 Q. And then in terms of the stroke team 23 being activated at 21:15, what would have been 24 the source of that time? 25 A. Usually that's a time stamp from the 0012 1 pager. So my common practice would be to put 2 that time in my note after the, you know, looking 3 through the pager and finding what time that call 4 actually arrived at the pager. 5 Q. In terms of your whereabouts, first of 6 all, do you have any recollection of where you 7 were when you received that page on August 17th, 8 2006? 9 A. I have no specific knowledge of where I 10 was at that time. 11 Q. Incidentally, do you have any 12 recollection of this particular patient or the 13 clinical scenario regarding this patient outsider 14 of what you recorded in your note? 15 A. I do not. 16 Q. In terms of the possibilities of where 17 you might be on August 17th, 2006, at 22:00, or 18 21:15, would you likely have been in the hospital 19 somewhere? 20 A. I was definitely on the hospital 21 property someplace. Neurology residents on call 22 are taking care of patients in any number of 23 locations around the hospital but are always on 24 campus at the time when they're on call. 25 Q. Why don't we go through your note, and 0013 1 what I would like to have you do is read it, and 2 as you read it, if you would just interpret your 3 abbreviations as you go, just as you would, you 4 know, read those as what they mean, basically. 5 And why don't we start with that. 6 A. Sure. So I designate myself at the top 7 of the note as a neurology senior. That means 8 that I was the supervising resident on call 9 overnight in the hospital. And I say this call 10 or this consultation is regarding a 51-year-old, 11 right-handed white male who is status post 12 pulmonary vein isolation procedure, that being 13 the name, apparently, of the cardiac procedure 14 that the patient had, today for chronic atrial 15 fibrillation. And I note in parentheses that he 16 was in normal sinus rhythm since the procedure. 17 That's pertaining to the heart rhythm that the 18 patient was in. 19 I then note that he was last normal at 20 20:30 during a nursing assessment. The 2 clot, 21 that being the stroke notification, was activated 22 at 20:15. The patient was noted to be quote, 23 "Not right," end quote. 24 On exam, the patient had a right MCA/ACA 25 syndrome. That means right middle cerebral 0014 1 artery slash, or in addition to, anterior 2 cerebral artery clinical syndrome, which 3 essentially involves the bulk of the, what's 4 commonly referred to as the anterior circulation 5 of the brain on the right side, that being the 6 territory supplied in most patients by the 7 carotid artery. 8 His clinical syndrome included what I 9 noted at the time of occular and eyelid apraxia. 10 That meaning that the patient was having 11 difficulty opening his eyes to command or moving 12 his eyes to command. He had left spatial 13 neglect, meaning that he was not attending to 14 objects or commands on the left-hand side of his 15 body. He had a positive sign of 16 somatoparaphrenia, which actually is an extreme 17 form of that spatial neglect involving, to the 18 point of denying existence or denying that your 19 own arm or your own leg belongs to you, thinking 20 that it's not your own. 21 He had a left facial droop. Meaning 22 that the facial muscles on the left side were not 23 working as well as the right side. His left 24 upper extremity motor strength I graded at less 25 than antigravity. That being, I graded at two 0015 1 over five, but having some motor activity. And 2 left lower extremity, four over five, meaning 3 antigravity, but sub total motor strength in that 4 leg, but apraxic, meaning he was having 5 difficulty following commands with it. 6 He had a reflex known as the left-sided 7 plantar reflex, which was spontaneously up-going. 8 That's a common neurological sign showing that 9 the upper motor neuron is affected on that side. 10 And then I note -- so that's where I stop noting 11 my examination, and begin noting what happened. 12 We took the patient apparently for 13 emergent CAT scan, that's computed tomography 14 scan, of the brain, CT angiogram and CT profusion 15 study, which I noted showed at the time a right 16 carotid occlusion and positive early infarct 17 signs. Those are signs which are associated with 18 brain tissue which has infarcted or stroked or 19 has begun dying on the brain scan. And I note 20 that there was a matched profusion deficit per 21 Ruggieri, that being Dr. Paul Ruggieri, a staff 22 neuroradiologist. 23 I note that we activated what's known as 24 the 2 flow system, that being the interventional 25 radiology system. It may have been staffed by an 0016 1 interventional radiologist, a neurosurgeon, or 2 neuroradiologist. I don't know who it would be 3 on that day, I didn't note that. 4 I note that I had multiple discussions 5 with staff, that being either a staff 6 neurologist, staff neuroradiologist or staff 7 neurosurgeon. I didn't note that specifically. 8 And it was decided that there was no 9 intra-arterial intervention that could be done 10 due to, it looks like a couple of factors, one is 11 the technical difficulty due to what apparently 12 was identified as a long segment of blood clot in 13 the petrous, that is one section of the carotid 14 artery, and also no likely benefit, plus 15 potential for harm given the size of the infarct 16 already visible on the CAT scan. 17 And then in my note it says, I should 18 note that there is something written in between 19 two lines here that says transseptal procedure 20 today with two stars next to it. I don't -- it 21 was common for these notes to have been addended 22 by an attending physician, and I don't know if 23 that there is actually my handwriting or someone 24 else's, given the fact that it's written in 25 between two lines. So I can't comment on me 0017 1 actually having written that. 2 And I note a plan, that is I have 3 annotated G-60, that is referring to, essentially 4 that in shorthand means admit the patient to the 5 neurological intensive care unit, put his head of 6 bed, HOB, flat, and keep systolic blood pressure 7 160 to 180 millimeters mercury ideally, using 8 normal saline boluses now. And those two latter 9 measures are designed to augment the profusion of 10 the brain and any potential areas of the brain 11 that was salvageable. 12 And then in the corner of my note I have 13 boxed off what is known as the NIH stroke scale. 14 The National Institutes of Health stroke scale is 15 a common convention which I would have written 16 it, detailing the subfindings on the exam and 17 then the total NIH stroke scale. 18 Q. Okay. Great, thank you. 19 Is the item boxed off with the NIH 20 stroke scale, is that your handwriting? 21 A. That is my handwriting, though that 22 probably appears multiple times throughout the 23 note. So the one that's associated with my -- 24 I'm sorry, throughout the chart. So that the one 25 associated with my note is my handwriting and the 0018 1 one that I would have done at the time. 2 Q. And would this NIH stroke scale have 3 been performed and documented at or about 22:00 4 hours? 5 A. I should mention that the first thing we 6 generally do when seeing these patients is go to 7 the bedside and examine them, so we'll generally, 8 literally run to the bedside, and start asking 9 the patient questions, starting to get a general 10 idea of what's going on, and the examination, the 11 neurological examination is a part of that. And 12 so the examination will have been the first thing 13 that took place. 14 The documentation of the examination 15 would have happened whenever things quiet down. 16 The general practice would be that we accompany 17 the patient to the scanner, and then while the 18 patient is actually getting the scan, start 19 writing a note. And so I generally timed my note 20 at 22:00. I don't know, you know, around that 21 time exactly when I did the examination versus 22 when I was actually writing my note, but that 23 would be the approximate time. 24 I think the times that I wrote in the 25 body of the note, that is last normal and the 0019 1 time that the 2 clot were activated, are reliable 2 times. I cannot tell you the time of 22:00, when 3 I've timed my note, I can't tell you when my 4 examination took place relative to that within 30 5 minutes or so. 6 Q. Okay. In terms of the events that took 7 place after your examination, beginning with 8 taken for emergent imaging, and continuing 9 through your plan, do you know how long those 10 events played out over, including, you know, 11 discussions with staff and getting the imaging 12 results back? 13 A. I do not know that. I didn't note those 14 times in my note and it's not convention to note 15 those things in a medical note. But I can tell 16 you that they generally happen very, very 17 quickly. This is viewed as an emergent event in 18 the hospital, and I've spoken, you know, when I 19 was doing this routinely and on call at night, I 20 have spoken to all of the staff that could be 21 involved from multiple departments. Everyone 22 responds very quickly, and so this generally is 23 something that happens very fast. 24 Q. In terms of determining whether the 25 patient is a candidate for IV thrombolytics and 0020 1 determining in terms of time wise, would you use 2 the 20:30 as the beginning time and then 23:30 as 3 the end time for that window? 4 A. With regard to the decision whether or 5 not to give thrombolytic therapy, and 6 specifically which thrombolytic therapy to give, 7 that decision ultimately rests solely with the 8 attending physician and is based on multiple 9 factors, as far as I understood it at the time. 10 One is the timing, as best we can estimate it, of 11 onset of the stroke. The other -- but that 12 timing needs to be checked with the emergent 13 imaging and other factors. That wouldn't -- the 14 decision of whether or not to give thrombolytic 15 therapy, it would not have been mine at the time. 16 Q. Okay. Thank you. In the left-hand 17 margin there is an INR and an ACT. Is that your 18 handwriting as well? 19 A. I cannot tell you whether or not that's 20 my handwriting. I am looking at a photocopy of 21 the note, and I can't tell strictly from looking 22 at the handwriting whether or not it's mine. 23 It's not my common practice to note ACTs; though, 24 because the patient was in an interventional 25 procedure on this date, I may have in this case. 0021 1 I really can't tell you yes or no. 2 Q. Do you know if, back in August of 2006, 3 whether you personally had been involved in 4 assessing a patient like this who was status post 5 pulmonary vein isolation that had a stroke? 6 A. I can't tell you that specifically, but 7 I can tell you that it was routine to be involved 8 with situations very similar to this and 9 answering the 2 clot pager responding to acute 10 strokes at least once per night, I would say on 11 average, though I can't tell you relative to this 12 procedure, this specific cardiac procedure, 13 exactly how many of these I saw. I don't recall 14 that. We're not required to keep track of those 15 sorts of things. 16 Q. Sure. And in terms of it being routine 17 to have similar situations like this, are you 18 talking about having, being called as the stroke 19 service to respond to a patient who has developed 20 a stroke in the hospital; is that what you are 21 referring to? 22 A. There are two places that we would get 23 calls from, one is within the hospital or one is 24 outside the hospital. Within the hospital, calls 25 could come from the hospital floor or the 0022 1 emergency room, and some patients would arrive 2 from places outside the hospital. And I can't 3 comment as to the frequency of those. 4 Q. Do you know which attending physician 5 made the decision not to use thrombolytics in 6 this patient? 7 A. I did not note that in my note and I 8 have no specific recollection of it. 9 Q. In terms of ordering an emergent CT, CTA 10 and CPT, is there a time frame in which you are 11 expecting that to occur? 12 A. So the process is not usually that we 13 order it. The process is -- this is why there 14 exists an acute stroke team consisting of 15 residents in the hospital, is because, like I 16 said, we would generally run to the bedside and 17 call the CT scan scanner and say, I'm coming down 18 with an acute stroke patient, be ready. And at 19 some point the order would be put into the 20 system, but we do not wait for transport. We get 21 the patient packaged up with whatever acute care 22 devices they need, and we go as soon as the 23 patient is stable enough to go. 24 Q. And then was the protocol -- so would 25 you meet the patient en route to the CT scanner 0023 1 or would you get to the patient's bedside and 2 then go with them as the stroke resident 3 physically attending them from where they were in 4 the hospital to the CT scanner? 5 A. That situation varies from patient to 6 patient, I would say. Generally one of the 7 neurology team will have met the patient prior to 8 going to the CT scanner, and there are multiple 9 clinical decisions that need to be made about 10 bringing the patient off the hospital floor where 11 they are when something acute is happening to 12 them. So I can't tell you who was the first 13 person to meet this particular patient or where I 14 specifically met them. 15 Q. In terms of in August of 2006, do you 16 know how many CT scanners there were at the 17 Cleveland Clinic? 18 A. I don't know that number. 19 Q. Did you ever have a situation as a 20 senior neurology resident where a CT scanner 21 wasn't available for an emergency CT, CTA or CPT 22 when you wanted one for a patient with a 23 suspected stroke? 24 MS. CARULAS: Objection. 25 Q. You can answer. 0024 1 A. I don't recall that ever coming up. 2 Q. Prior to your involvement with the 3 patient, if you go back a few pages in the 4 progress notes, there is a note at 21:30, it's 5 approximately a three-page note. Do you 6 recognize the handwriting or can you tell me who 7 this junior stroke resident was that prepared 8 that note? 9 A. I do not recognize the handwriting but 10 the note is signed Taub, T-A-U-B, and I recognize 11 that as someone who was a neurology resident at 12 the time. 13 Q. And I see a word, Julia. Is it Julia 14 Taub or is that someone else? 15 A. Julia, is her first name, yes. But 16 that's in handwriting. 17 Q. And do you know if currently Dr. Taub is 18 at the Clinic? 19 A. I haven't corresponded with her in a 20 long time, but I think that she is functioning in 21 some capacity at the Clinic currently. 22 Q. And her note is timed at 21:30, and then 23 Dr. Abou-Chebl's notes is timed at 9:22 a.m. on 24 the 18th, and then your note is on the 17th, the 25 next note, at 22:00. So they sort of appear to 0025 1 be out of sequence. Can you tell me how that 2 occurred or why that occurred, if you know? 3 A. Like I said, the common practice with 4 these situations is that things are happening 5 very quickly. Generally, Dr. Taub or the junior 6 neurology resident at the time and the senior 7 neurology resident at the time would be seeing 8 the patient nearly simultaneously, and also 9 writing their notes simultaneously, given any few 10 minutes of a break in the action, if you will. 11 Those notes are generally written on individual 12 pieces of paper and then subsequently bound into 13 the chart. 14 And so if you are writing a note 15 simultaneously with someone else, we're writing 16 on separate pieces of paper that then get bound 17 into the chart, generally by a unit secretary, 18 and it may not necessarily be in chronological 19 order. The staff physician will then go back and 20 annotate any specific portions of either of the 21 notes that he chooses to, and then will generally 22 write the note at the bottom of the junior 23 resident's note, which tends to be the 24 more-detailed one. 25 Q. Do you have any specific recollection of 0026 1 talking to a neurology attending or stroke 2 attending at any time between 21:15 when you were 3 first paged and August 18 at 9:22 a.m. when Dr. 4 Abou-Chebl prepared his note? 5 A. I have no specific recollection of that 6 in this case. 7 Q. Back in -- well, let me ask the same 8 question with respect to Dr. Taub. Do you know 9 if Dr. Taub had any direct communications with 10 any stroke attending or neurology attending 11 between her note at 21:30 on August 17 and Dr. 12 Abou-Chebl's note on August 18 at 9:22 a.m.? 13 A. I haven't had the opportunity to read 14 her note in detail, and I don't know whether she 15 noted anything like that. But as of right now, I 16 do not have any knowledge of her specifically 17 speaking to anyone, based on what I've read in my 18 note. 19 Q. In terms of training, were stroke 20 residents trained to chart in their progress 21 notes, their initial progress note for a patient 22 with a suspected note, to chart any 23 communications that they had with attending 24 physicians regarding patient care? 25 A. There is no specific training within the 0027 1 confines of a neurology residency about that sort 2 of thing. 3 Q. Were there any policies or procedures 4 back in August of 2006 that you were aware of 5 that required a stroke resident to contact an 6 attending following an initial evaluation of a 7 suspected stroke patient? 8 A. I know of no specific policies, though 9 it was the common practice for the senior 10 neurology resident to talk to an attending 11 physician about the patient whether or not to 12 administer thrombolytics at the time, and I did 13 note in my notes that I did have a conversation 14 with an attending. I just don't know which 15 specific one it was. 16 Q. Can you tell me whether that 17 conversation took place within the three hour 18 window for administration of thrombolytics? 19 A. I can't tell you that. 20 Q. We talked about the difference between 21 arterial thrombolytics and IV thrombolytics. Do 22 you know whether, in August of 2006, whether the 23 Clinic was using arterial administration of tPA 24 or thrombolytics in that time frame? 25 A. Yes, the Clinic was using thrombolytics 0028 1 in an off-label or, in other words, non 2 FDA-approved manner at that time. Again, the 3 decision would have been through the team, which 4 I designate in my note as 2 flow, who apparently 5 I discussed the case with. 6 Q. Let me ask you about that. In terms of 7 that 2 flow, what does that mean? Maybe you said 8 this, I apologize, I didn't write down what you 9 said. 10 A. That's the mnemonic device which is 11 given to the pager carried by any one of a number 12 of interventional neurology, neuroradiology, 13 neurosurgery staff. There would generally be one 14 on call on any given night and they pass the 15 pager off to, you know, based on whichever days 16 they are on call. So that we basically, as 17 people in the hospital, only have to remember one 18 number to call, and it avoids a step of having to 19 look up a specific person. 20 Q. Based on your charting practices back in 21 August an of 06, when you say that you had 22 multiple discussions with staff, could that refer 23 to discussions with residents as proxies for 24 staff? 25 MS. CARULAS: Objection. 0029 1 A. Based on my charting practices, when I 2 put staff, I mean staff referring to an attending 3 physician, never to a resident or a fellow. 4 Q. And is there a place in the record to 5 your knowledge where I could look to identify who 6 the 2 flow personnel was staffing, or the 7 personnel staffing 2 flow at this time frame? 8 A. I assume there was a call schedule at 9 one point in time for August of 2006, though I 10 don't know how formal or informal that schedule 11 was or if it's still available. I can tell you 12 that I, based on my note, called that number and 13 discussed things with a staff physician. That's 14 all I know. 15 Q. And in terms of the things that you 16 would have discussed, given the time frame of 17 August of 06, do you think you likely discussed 18 IV tPA? 19 A. I think that I probably did discuss IV 20 tPA given the times involved, and after having 21 reviewed again entries on this patient's chart 22 that I made, the fact that I actually ordered IV 23 tPA to the patient's bedside, which was my common 24 practice in any case which was within a three 25 hour window in which we could potentially need 0030 1 the drug, again, functioning as a neurology 2 resident in the hospital as the relative first 3 responder, if you will, it's my job to make 4 preparations to help the patient if at all 5 possible. 6 Q. In terms of this conversation with 2 7 flow, would you, again, given the time frame of 8 August of 2006, likely have discussed arterial 9 thrombolytics? 10 A. I don't know specifically what the 11 material of my discussion was with this staff, 12 though I noted in my note that it was decided 13 that there would be no intra-arterial therapy and 14 likely no IV -- IV being the notation for IV 15 tPA -- based on the factors that I noted earlier. 16 Q. Okay. 17 A. I assume that that conversation actually 18 took place. 19 Q. And besides those two potential 20 interventions, and again given the time frame 21 August of 06, was there likely any discussion of 22 any other intervention with 2 flow? 23 A. The only interventions that I know of 24 are the intra-arterial and the intravenous 25 therapies. I don't denote in my note 0031 1 particularly which intra-arterial therapies, and 2 that would not have been up to me. 3 Q. Okay. I'm going to hand you what I'll 4 mark as exhibit 3. It's a subsequent progress 5 note from the EP staff dated August 18 at 7:30 6 a.m., and towards the bottom there is a 7 discussion by one of the EP staff, Dr. Cummings. 8 She states, "Patient without cardiac diagnosis. 9 There is no contraindication to any aggressive 10 neuro treatments deemed necessary at this time, 11 including anticoagulation/thrombolysis." 12 Do you recall having any discussions in 13 this time frame about EP's view with respect to 14 the use of thrombolytics in the face of a patient 15 like Mr. Sullivan who has a stroke after an afib 16 procedure? 17 A. (Reading.) 18 (Deposition Exhibit 3 was marked for 19 purposes of identification.) 20 A. I'm sorry, I didn't understand. You 21 were referring to her note, but then you, I think 22 you were asking whether or not I had a 23 conversation with somebody? 24 Q. Yes. What I'm trying to understand is, 25 in light of the fact that you were in training at 0032 1 the time, is whether or not, as I refer to this 2 note here from the EP staff, it looks like 3 they're trying to communicate their position with 4 respect to thrombolytics. And I'm asking you, by 5 virtue of your position as a trainee, do you 6 recall any discussions about the use of 7 thrombolytics in post ablation patients based on, 8 you know, this note that we've just read? 9 A. As I've stated before, I have no 10 specific recollection of things that happened in 11 this case, so my knowledge is limited to what I 12 wrote down in my notes. 13 I can tell you that based on what I 14 wrote in my note, I was concerned with the 15 neurology of the case, that being, you know, in 16 the best-case scenario, if this patient, you 17 know, were, if you will, cleared by the people 18 who did his procedure, would there be a potential 19 benefit over and above the harm that's possible 20 from giving thrombolytics. And I don't think we 21 ever even got to the question of whether he was 22 really eligible, because there was a large stroke 23 on his CAT scan already, and in that situation, 24 we don't give intravenous tPA for fear of doing 25 harm, essentially. 0033 1 Q. Do you think that you contacted the EP 2 service at any time between being initially 3 contacted on August 17 at 21:15 and this note by 4 the EP staff at 7:30 a.m. on August 18? 5 A. I did not make any notations one way or 6 the other with regard to that. 7 Q. Is that something that you typically 8 would chart if you had contacted the EP staff? 9 A. I don't think that's something that I 10 typically had a policy on. 11 Q. Do you know if there was any policy or 12 procedure back in August of 2006 at the Cleveland 13 Clinic that required a resident such as yourself 14 in a post-surgery patient to contact -- post 15 surgery patient that you are consulted with 16 respect to a suspected stroke, to contact the 17 surgical service to get their input on treatment 18 of the stroke? 19 A. I don't know of any specific policies 20 that were in place regarding that. Again, my 21 involvement was with regard to the neurology of 22 the case, and whether or not based on the timing 23 and the extent of the patient's stroke, they were 24 eligible for any potential neurological therapy. 25 And that decision doesn't rest with me, it would 0034 1 have rested with the attending physician. 2 Q. Understood. You chart in your note, 3 however, a discussion of the potential benefits 4 and potential risks of IV tPA, and let me just 5 try to understand, from your perspective back in 6 August of 06, what those likely benefits and 7 likely potential for harm would be that you would 8 have considered back then. 9 A. Do you have a question? 10 Q. Yes, sure. So you write down here that 11 no likely IV benefit, plus potential for harm. 12 And I want to ask you just specifically about 13 that. What was the potential for harm that you 14 are referring to? 15 A. Let me frame this by saying this 16 sentence begins with me saying I activated 2 17 flow, that being the interventional team, and 18 after multiple discussions with staff, we 19 decided, and then talk about the risks and 20 benefits things. So what I note here -- 21 Q. Let me ask a different question, because 22 I respect what you are saying and I understand 23 why you are frustrated with me, so let me ask it 24 a fairer way. 25 A. Go ahead. 0035 1 Q. Based on the way you have charted this, 2 do you know what the potential for harm that the 3 staff was concerned about was as you chart here? 4 A. The harm, the potential for harm 5 associated with any thrombolytic therapy involves 6 bleeding risk, and that risk is substantially 7 higher in patients who have sizeable stroke, that 8 being greater than one-third of the middle 9 cerebral artery territory as convention had it at 10 that time. 11 Q. So specifically in terms of what you 12 have charted here, the potential for harm, you 13 are talking about the potential for bleeding in 14 the brain in the area of the infarction; is that 15 it? 16 A. There are multiple risks associated with 17 thrombolytic therapy. I have had patients have 18 bleeding in the bladder, resulting in myocardial 19 infarctions and other severe complications, 20 bleeding into the brain, bleeding into the GI 21 tract, which can be life threatening. Bleeding 22 into the brain is one of the ones that we are 23 most concerned with when someone has a sizeable 24 stroke. 25 Q. Do you know, back in August of 06, what 0036 1 was sort of the appreciated risk of complication 2 from thrombolytic therapy in the face of an acute 3 stroke? 4 A. If you are asking me for a percentage 5 risk, I do not know in August of 2006 what that 6 percentage risk was appreciated as, but I know 7 there were certain factors which were thought to 8 increase the risk of intracerebral hemorrhage 9 following IV tPA, including the clinical deficit 10 and the degree of the clinical deficit that -- 11 meaning that more clinical deficit implied a 12 larger stroke, and also, quote, "signs of early 13 infarct" on the CAT scan, which implied that some 14 of the brain tissue had already been infarcted 15 and was potentially a source of bleeding if you 16 got thrombolytics. 17 Q. Okay. Any other factors that you can 18 think of that would increase the risk in this 19 particular patient for a bleeding complication, 20 besides the size of the stroke, the signs of 21 early infarct, and the degree of deficits? 22 A. Like I said, the decision, at least as 23 far as I'm interpreting my own note here, was 24 based primarily on the neurology of the case, 25 that being essentially the size of the stroke 0037 1 already present on the CAT scan. 2 Q. In terms of your training, was there any 3 change in the way you evaluated patients for tPA 4 administration subsequent to August of 06? In 5 other words, you know, based on your training 6 subsequent to that point in time, would this 7 patient likely have been a candidate for tPA 8 administration? 9 MS. CARULAS: Objection. 10 A. I have to say that I haven't kept up 11 with the literature since I have become a 12 multiple sclerosis subspecialist. 13 Q. Did you make a determination as to what 14 caused his stroke in the first place? 15 A. I make no notations in my note as to 16 potential mechanisms of the patient's stroke. 17 Q. Do you have an opinion today, based on 18 reviewing the record? 19 A. Beyond the fact that it's noted in my 20 note that there was a, quote, "long clot in 21 petrous," which would indicate the petrous 22 portion of the carotid artery, it appears that 23 this would be an ischemic stroke caused by a 24 blood clot in the carotid artery, though I don't 25 know the source of that. 0038 1 Q. I have seen reference to CCF, or 2 Cleveland Clinic being an acute stroke center 3 currently. Was it considered an acute stroke 4 center back in 2006? 5 A. I wasn't involved in that accreditation 6 process and I don't know. 7 Q. When you talk about responding to a 2 8 clot page and you mention the running to the 9 patient's bedside, would it likely be the junior 10 resident that would be running to the patient's 11 bedside and that would account for the difference 12 between her note being at 21:30 and your note 13 being roughly timed a half hour later? 14 A. I do not think that that can be said as 15 the explanation for the difference in timing of 16 the notes. Like I said, the writing of the note 17 is generally the lowest priority. Taking care of 18 the patient is the highest priority. And I can't 19 vouch for the timing within minutes of those 20 notes being exactly when the personal got there 21 versus when the notes were written. I just don't 22 know the answer to that. 23 I can tell you that whoever was closest 24 to the patient, the junior or the senior 25 neurology resident, would have been the first one 0039 1 to get there. Though generally, they get there, 2 you know, within minutes of each other. 3 Q. And really what I'm getting at, Dr. 4 Bermel, is that your note indicates that 2 clot 5 was activated at 21:15. Your note is timed about 6 45 minutes later, and Dr. -- 7 MS. CARULAS: Taub. 8 Q. Taub's note is timed about a half hour 9 after that time for activation. Is it acceptable 10 for the stroke service to respond a half hour or 11 45 minutes after being activated in a 12 circumstance like this? 13 MS. CARULAS: Objection. 14 A. I think it's unlikely that it took that 15 long to respond, based on what I know about the 16 history. And I would say that generally, the 17 common practice in the medical record is that the 18 time that appears in the left-hand margin of 19 those notes is the time at which the note was 20 being written. And like I said, that, the 21 writing of the note is generally the lowest 22 priority. The highest priority being taking care 23 of the patient, getting the patient to the CAT 24 scanner, talking to the people who need to be 25 talked to. 0040 1 And so, though my note itself is timed 2 as being written at that time, I think it's 3 likely that we got to the bedside substantially 4 sooner than that; likely within minutes of when 5 the pager was activated. 6 Q. Based on common practice back in August 7 of 06, would you and Dr. Taub both likely conduct 8 an assessment of the patient or would it usually 9 be one or the other doing an assessment? 10 A. It was the common practice for each 11 person to perform an independent assessment, 12 though I can't tell you in which order they would 13 have been or exactly when they occurred relative 14 to each other. 15 Q. In terms of contacting an attending, as 16 you note that you have discussions with staff, 17 would that typically be done via a pager service 18 or by cell phone or some other way? 19 A. I can't tell you the way in which it 20 happened in this particular situation, but 21 generally, it's a neurology resident talking 22 directly with an attending physician, not via an 23 intermediary or anything like that. 24 Q. Okay. Was the practice back in 06 for 25 the stroke team resident to page an attending? 0041 1 MS. CARULAS: I'm going to object. I 2 think he's already been through this. That he 3 pages this, and whoever is on call -- 4 A. I think generally if you are talking 5 about the 2 flow pager, like I said, we would 6 contact that pager and the attending would call 7 back. 8 Q. And I apologize, but would there be a, 9 to your knowledge, would there be a record of 10 that page? 11 A. I don't know if there is any record of 12 that. 13 (Deposition Exhibit 4 was marked for 14 purposes of identification.) 15 Q. Doctor, I'm going to hand you what I've 16 marked as exhibit 4. And just to clarify, I 17 think you told us earlier, but I just want to 18 confirm, is this your order for the tPA sort of 19 set up in the event that it was requested by an 20 attending or ordered by an attending? 21 A. Correct. 22 Q. In a situation like this, where you 23 order an emergent imaging and you go with the 24 patient down to where the imaging takes place, do 25 you also make arrangements to have a radiologist 0042 1 available to read the films with you when they're 2 ready? 3 A. That's a highly variable situation. I 4 would say that it's important to us to have a 5 staff radiologist interpret the images, and it 6 looks like that happened in this case, though I 7 can't tell you exactly how, the mechanics, you 8 know, behind how it happened. 9 Q. Tell me what in the records that you 10 have reviewed suggest to you that a staff 11 radiologist, in fact, looked at these films 12 emergently? 13 A. Well, I noted in my note that the CT, 14 CTA, CPT showed right carotid occlusion and 15 positive early infarct signs and a matched 16 profusion deficit per Ruggieri. That would be 17 the staff neuroradiologist, Paul Ruggieri. 18 Q. Okay. Thank you. Would you also review 19 the films in a scenario like this? 20 A. Generally I also would have looked at 21 the films. 22 Q. Going back to the note that we looked at 23 earlier from the EP staff that we marked as 24 exhibit 3, do you have any recollection in this 25 time frame, August of 06, and as part of your 0043 1 training when a patient developed a stroke after 2 an ablation procedure, that there was any change 3 in policy or practice such that the EP service 4 would be notified in a situation like this? 5 MS. CARULAS: Objection. 6 A. I don't understand the question. 7 Q. Sure. What I'm wondering, I'm reading 8 this last note here, where Dr. Cummings from the 9 EP service makes a note about how the EP service 10 looks at a situation like this. And what I'm 11 asking you is, there was any coordination between 12 the stroke service and the EP service regarding 13 patients like Mr. Sullivan who have a stroke 14 after an ablation procedure in terms of either 15 contacting the EP service to get their input or 16 anything like that? 17 MS. CARULAS: Same objection. Go ahead. 18 A. I don't know of any particular policy 19 with regard to that. 20 Q. But in terms of your training, in terms 21 of what you should do in same or similar 22 circumstances, do you have any recollection of 23 there being any, you know, training moment or 24 change in procedure where EP would be advised of 25 a patient like Sullivan who develops a stroke 0044 1 after an ablation procedure? 2 MS. CARULAS: Objection. 3 A. Personally, I don't know of any such 4 policy. 5 Q. Okay. Thank you. Let me just see that, 6 the order, please. 7 A. (Indicating.) 8 Q. Doctor, as I go through the orders, and 9 I can show you what I have in terms of orders, I 10 don't see an actual written order for the 11 emergent CT scan, and maybe that's common in a 12 situation like this, where you are trying to get 13 the patient down there as quickly as possible. 14 Was that the case, that you wouldn't necessarily 15 document an order for an emergent CT scan in a 16 situation like this? 17 A. I don't know about this particular 18 situation. I can't comment with regard to your 19 ability to find the order or not; but I can tell 20 you that as the first responder, my concern is 21 physically getting the patient to the CT scanner 22 and getting the scan done as soon as possible. 23 Generally, the technologist will require the 24 order be in the, quote, "in the system" for that, 25 though I don't know whether in this situation 0045 1 that would have been, you know, noted in the 2 chart or not. 3 (Deposition Exhibit 5 was marked for 4 purposes of identification.) 5 Q. I'll hand you what I've marked as 6 exhibit 5, and it's two pages of electronic 7 medical records, the electronic physician's 8 orders, and I certainly wasn't meaning to trick 9 you, but as I look at this, there appears to be 10 an electronic order for the CT scan, however, 11 it's under the name of Dr. Cummings who is from 12 that EP service. Let me just show it to you and 13 then ask you a couple of questions. 14 Do you know if it would be the case that 15 maybe you would order the CT scan as the 16 responding senior stroke resident, and then 17 attending would then come back and somehow enter 18 the order in under their name? And let me just 19 ask it more broadly. Do you have an explanation 20 for why Dr. Cummings, who apparently didn't see 21 the patient until the 18th, why she would have 22 been noted as ordering the CT scan on the 17th? 23 MS. CARULAS: Same objection. If you 24 know. 25 A. I'm generally, I'm just looking -- I'm 0046 1 not familiar, first of all, with the document 2 that you have provided me with, so I'm taking a 3 moment to look it over. I don't have exposure to 4 this sort of a record usually. It looks like it 5 contains only the names of attending physicians 6 as ordering providers, and I can tell you that, 7 as far as the mechanics of getting the study 8 done, it may have been possible that the study, 9 the order for the study was attributed to any 10 available physician and conceivably to the 11 patient's primary attending physician at that 12 time. 13 (Deposition Exhibit 6 was marked for 14 purposes of identification.) 15 Q. I'll mark as exhibit 6 a three-page 16 document that purports to be a copy of the record 17 from the imaging study. Let me hand that to you 18 and just give yourself a chance to acquaint 19 yourself with it. 20 A. (Reading.) This looks like a very 21 detailed, official report for a CT scan of the 22 brain with a CT angiogram. 23 Q. Can you tell from that document, doctor, 24 when the films would have been ready for 25 preliminary review after they were taken? 0047 1 A. There is nothing on this document that I 2 can get that information from. 3 Q. And maybe you are just not familiar with 4 it, and that's fine, too, but I'm just trying to 5 understand it. There is a note on here that says 6 that it's ordered at 10:08 on 8-17, and then 7 there is a note on here that says that the exam 8 was performed at the same time on 8-17, and do 9 you know what those refer to in terms of -- is 10 that just maybe when the order was entered or can 11 you tell me what those times refer to? 12 A. As a neurology resident, I have no 13 knowledge of the way the Cleveland Clinic medical 14 records system times orders, but that also 15 confused me. 16 Q. Okay. 17 A. In that I don't know whether it refers 18 to the time the exam was performed or the time 19 that the test was ordered. 20 Q. And likewise, where it says result 21 information, final result, and then it says 22 August 18 at 12:29 a.m., do you know what that 23 refers to? 24 A. I do not. 25 Q. Do you know if there is any way for me 0048 1 to go back and tell when these film were ready 2 for review? Is there someplace where that 3 information would be documented? 4 A. Generally an imaging study will have a 5 time stamp on it. 6 Q. And the likelihood would be that from 7 the time that was available, you would be present 8 to evaluate it relatively soon after it's 9 available, is that what I should understand from 10 the way these things work with the stroke 11 service? 12 A. That's the intent. The CAT scan of the 13 brain would be available for interpretation 14 almost immediately as soon as it's performed; 15 however, the additional portion of the study, 16 that being the CT angiogram and the CT profusion 17 study, I'm not an expert in this, but from my 18 experience being there when some of these are 19 down, they require computerized reconstruction 20 and some other computerized post processing, 21 which takes some amount of time, and I don't know 22 how much time that is specifically. 23 Q. Are you familiar with the American 24 Stroke Association's guidelines for early 25 management of patients with ischemic stroke that 0049 1 existed in 2006? I think the edition in effect 2 as of 2006 was a 2003 edition. 3 A. I would have probably read those 4 recommendations during my training at some point, 5 but I am less familiar with them now that I'm a 6 subspecialist in multiple sclerosis. 7 Q. Fair enough. And let me just represent 8 to you that the guidelines from 2003 state that 9 the presence of early infarct signs, even if they 10 involve greater than one-third of the MCA 11 territory in patients with a well-established 12 stroke onset time of less than three hours, does 13 not preclude treatment with IV tPA or suggest an 14 unfavorable outcome to therapy. And just assume 15 that's what it says. Can you tell me how this 16 case would be different than what the ASA talks 17 about there? 18 MS. CARULAS: Objection. 19 A. So, again, I don't have any specific 20 recollection of this beyond what I noted in my 21 note, and my role in this was primarily a 22 facilitator, and I can tell you that I spoke, 23 based on my note, with the experts in our field, 24 that being a neuroradiologist and someone 25 associated, a staff physician associated with the 0050 1 2 flow pager who make those sorts of 2 determinations. And apparently, the 3 determination that they made was that there was 4 more potential for harm that outweighed the 5 potential for benefit in this case. 6 Q. As a resident, if an EP attending had 7 told you that there is no contraindication to 8 thrombolysis in this patient, would that be the 9 kind of order that you as a stroke resident would 10 be required to follow? 11 MS. CARULAS: Objection. 12 A. An attending physician telling someone 13 that there is no contraindication to something is 14 not an order. 15 Q. Well, let me ask it differently then. 16 Let's say that Dr. Cummings felt that tPA was 17 indicated in this patient. If she as an 18 attending had communicated that to you as a 19 resident, is that the type of order that you 20 would be required to follow? 21 MS. CARULAS: Objection. 22 A. Generally, it's a very cooperative 23 atmosphere in the hospital, and my experience of 24 being on the stroke team -- again, not in 25 reference to this particular case, but in 0051 1 general -- was that the other services, including 2 the cardiology services, rely heavily on the 3 stroke team, because of their level of expertise 4 on this, to make the call with regard to these 5 sorts of decisions. And I do not recall any 6 instance in this hospital where someone other 7 than a physician, an attending physician 8 associated with the stroke team, has administered 9 intravenous tPA for reasons of stroke. 10 Q. Just so I understand it -- I think you 11 told me this, but I want to make sure I'm not 12 mistaken -- in terms of the stroke team, that 13 would include people besides potentially 14 neurology such as interventional radiologists; 15 right? 16 MS. CARULAS: Objection. 17 Q. Is that right? 18 A. So I guess it depends how you define the 19 stroke team. 20 Q. That's what I'm asking, really. 21 A. But there are collaborations, you know, 22 with neuroradiologists, neurologists, potentially 23 neurosurgeons who have a specific area of 24 expertise in that area, all who collaborate on 25 these cases at some point. 0052 1 Q. All right. 2 A. So I can't tell you which of these 3 people specifically was involved in this case. 4 Q. Okay. I understand that. Would 5 potentially interventional radiologists be part 6 of the stroke team decision-making? 7 A. In general, we would involve what we 8 call the 2 flow team at the time in decisions 9 about whether or not to pursue intra-arterial 10 therapy, because they're the ones who would be 11 performing intra-arterial therapy. 12 Q. Who would make the decisions with regard 13 to intravenous therapy? 14 A. In general, the decision would be made 15 by the staff who was on the stroke team, though I 16 don't have any specific knowledge of who that 17 person was in this case. 18 Q. From the record, it appears that the 19 first time a stroke attending is aware of the 20 patient is Dr. Abou-Chebl's note on August 18. 21 Would you agree with that? 22 MS. CARULAS: Objection. 23 A. I haven't gone through the record in 24 detail to be able to tell you that. 25 Q. Is the NIH-SS scale or index used to 0053 1 indicate prognosis or to determine prognosis? 2 A. Again, you are asking a multiple 3 sclerosis expert primarily to comment on a stroke 4 scale. As far as I understand it, it's first and 5 foremost a research tool, secondly a 6 communication tool between team members, so that 7 when I say this person has a NIH stroke scale of 8 16, the person, the neurologist that I'm talking 9 to, has some understanding of what that is. 10 Q. Okay. I think I'm done. Give me a 11 second to cover my work here to make sure I'm 12 done. I don't know if you want to take a break 13 or anything. It will just take about five 14 minutes or so. 15 A. Great. 16 (Recess had.) 17 MR. KULWICKI: All right. I think I'm 18 done. 19 MS. CARULAS: I'm going to have him 20 waive signature, so we won't have to worry about 21 that. 22 23 (Deposition concluded at 11:51 a.m.) 24 ~ ~ ~ ~ ~ 25 0054 1 CERTIFICATE 2 3 The State of Ohio, ) SS: 4 County of Cuyahoga. ) 5 I, Nayann B. Pazyniak, a Notary Public within and for the State of Ohio, duly 6 commissioned and qualified, do hereby certify that the within named witness, ROBERT BERMEL, 7 M.D., was by me first duly sworn to testify the truth, the whole truth and nothing but the truth 8 in the cause aforesaid; that the testimony then given by the above-referenced witness was by me 9 reduced to stenotypy in the presence of said witness; afterwards transcribed, and that the 10 foregoing is a true and correct transcription of the testimony so given by the above-referenced 11 witness. I do further certify that this 12 deposition was taken at the time and place in the foregoing caption specified and was completed 13 without adjournment. I do further certify that I am not a 14 relative, counsel or attorney for either party, or otherwise interested in the event of this 15 action. IN WITNESS WHEREOF, I have hereunto set 16 my hand and affixed my seal of office at Cleveland, Ohio, on this 5th day of April, 2010. 17 18 19 Nayann B. Pazyniak, Notary Public 20 within and for the State of Ohio 21 My commission expires October 26, 2011. 22 23 24 25 0055 1 SIGNATURE OF WITNESS 2 3 4 5 6 The deposition of ROBERT BERMEL, M.D., was 7 taken in the above-captioned matter on the date, 8 time and place set out on the title page hereof. 9 10 It was requested that the deposition be taken 11 by the reporter and that same be reduced to 12 typewritten form. 13 14 It was agreed by and between counsel and the 15 parties that the reading and signing of the 16 transcript of said deposition is hereby waived. 17 18 19 20 21 22 23 24 25