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. 7 The Cleveland Clinic ) CV-09-697617 Foundation, ) 8 ) Defendant. ) 9 10 - - - - - 11 12 Deposition of: JULIA TOUB, M.D. 13 14 15 May 11, 2010 6:04 p.m. 16 17 18 Location: Cleveland Clinic Foundation 9500 Euclid Avenue 19 Cleveland, Ohio 20 21 Reporter: Christine Leisure, Notary Public 22 23 24 25 0002 1 APPEARANCES: 2 3 On behalf of the Plaintiffs (via telephone): DAVID A. KULWICKI, ESQ. 4 Becker & Mishkind Co., LPA 1660 West Second Street 5 Skylight Office Tower, Suite 660 Cleveland, OH 44113 6 866.477.4097 dkulwicki@beckermishkind.com 7 8 On behalf of the Defendant: 9 ANNA MOORE CARULAS, ESQ. Roetzel & Andress, LPA 10 1375 East Ninth Street One Cleveland Center, Ninth Floor 11 Cleveland, OH 44114 216.623.0150 12 acarulas@ralaw.com 13 14 - - - - - 15 16 17 18 19 20 21 22 23 24 25 0003 1 I N D E X 2 EXAMINATION OF JULIA TOUB, M.D. 3 Page Line 4 BY MR. KULWICKI...................4 6 5 6 7 EXHIBITS MARKED 8 Deposition Exhibit 1 .............6 3 9 10 - - - - - 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0004 1 JULIA TOUB, M.D., of lawful age, called 2 for examination, being by me first duly sworn, as 3 hereinafter certified, deposed and said as 4 follows: 5 EXAMINATION OF JULIA TOUB, M.D. 6 BY MR. KULWICKI: 7 Q. Good afternoon, Dr. Toub. 8 If you would kindly state your name and 9 spell your last name for the record. 10 A. Sure. It's Julia Toub, T-o-u-b. 11 Q. And, Doctor, what is your current status 12 with the Cleveland Clinic? 13 A. I am an epilepsy fellow. 14 Q. And going back to August of 2006, where 15 were you at in your training? 16 A. I was in my second month of neurology 17 training. 18 Q. When will your current -- your 19 fellowship terminate? 20 A. At the end of June. June 30th of this 21 year. 22 Q. And do you have plans as to where you'll 23 be at the conclusion of your fellowship? 24 A. Yes, I have accepted a position in 25 Portland, Oregon. 0005 1 Q. Okay. Do you have an address in 2 Portland yet? 3 A. No, not as of yet. 4 Q. Do you know the name of the facility 5 that you'll be at in Portland when you transfer 6 out there? 7 A. Providence Health System, St. Vincent 8 Hospital. 9 Q. Okay. Doctor, we're here to talk about 10 your involvement in the care of a patient by the 11 name of Shannon Sullivan. 12 Do you remember Mr. Sullivan or your 13 involvement in his care in any respect? 14 A. I do. 15 Q. Tell me, do you remember him such that 16 you have a picture in your mind of what he looks 17 like such that you could describe him, or is your 18 recollection limited to the detailed note that 19 you prepared regarding your encounter with the 20 patient? 21 A. Mostly limited to my note. 22 Q. Okay. Let's turn to that note, and by 23 your note -- 24 MR. KULWICKI: Christy, if you have it 25 there, let's go ahead and mark it as Exhibit 1. 0006 1 It's a three-page note dated August 17, 2006 at 2 2130. 3 (Deposition Exhibit 1 was marked for 4 purposes of identification.) 5 Q. And just by way of overview, there is -- 6 in the left-hand column there is some handwriting 7 that appears to be a little different than what 8 is in the main body of the note. 9 We deposed Dr. Abou-Chebl and Dr. Bermel 10 and I can't remember which of them told us that 11 that was their handwriting, but I want to confirm 12 with you if indeed the handwriting in the 13 left-hand column is someone other than yours. 14 A. Yes, sir, it is not my handwriting. 15 Q. Okay. And do you know if when you 16 prepared your note you were attending to the 17 patient at the same time as Dr. Bermel, the 18 senior stroke resident? 19 A. Well, from what I can remember, the note 20 was prepared after we assessed the patient so our 21 notes were written at separate times. I couldn't 22 vouch for when he wrote his note. 23 Q. Okay. And when you say "we," you mean 24 you and Dr. Bermel? 25 A. Correct. 0007 1 Q. And you would have assessed the patient 2 at the same time; is that correct? 3 A. Yes, sir. 4 Q. Okay. Now, one of the things that I was 5 interested in, and really the reason why I wanted 6 to talk to you, was the very last thing in your 7 note where it says, number 4, "Will discuss with 8 staff in the a.m." 9 A. Yes. 10 Q. Tell me what that means. 11 A. So basically that's kind of standard for 12 any notes written by residents or fellows while 13 on call. Basically anything urgent is discussed 14 over the phone at night, kind of on the spot 15 during the acute issue, but any other kind of 16 issues that arise over the course of the night 17 will be discussed in further detail on the 18 following morning. 19 And that's kind of code, we pretty much 20 write that at the end of all of our notes. 21 Q. Going to the first page of your note, 22 under the history of present illness it says, 23 "The cardiology fellow was emergently notified 24 and the stroke team was alerted." And it looks 25 like Dr. Abou-Chebl wrote to the right of that 0008 1 "Arrived within a few minutes," referring to, I 2 believe, the stroke team. 3 Let me ask you about that. Can you tell 4 me with some greater detail what that refers to, 5 the stroke team alerted? 6 A. Yes. So basically whenever there is an 7 acute stroke in the hospital or a suspected 8 stroke, there's a protocol in place where nurses 9 and caretakers on the floor are instructed to 10 page a standard pager, which is the 2 Clot pager. 11 That pager is generally carried by the senior 12 neurology resident that's on call for the 13 evening. In this case it was Dr. Bermel. 14 When that pager goes off, we generally 15 drop whatever we're doing and go immediately to 16 wherever the call is placed from. 17 Q. And we had learned in the prior 18 depositions that there was the 2 Flow and the 19 2 Clot teams. Would the stroke team be the 20 2 Clot team? 21 A. Yes, that's correct. 22 Q. And you would have been a member of that 23 team? 24 A. Yes. 25 Q. When the 2 Clot team is contacted, is it 0009 1 typically residents and/or fellows that respond 2 immediately? 3 A. It's typically residents. Fellows do 4 not take in-house call. 5 Q. Now, going to the second page of your 6 note down to the assessment and plan under item 7 number 1, it says, "Stroke fellow/staff paged." 8 Can you tell me what that likely refers 9 to? 10 A. So that refers to -- there's always a 11 fellow that's on call for the night from home, so 12 that fellow would have been alerted, as well as 13 there is a staff that's on call for the evening 14 as well, and that staff would have been alerted. 15 And whether that staff is the one that's 16 carrying -- some nights it's the one carrying the 17 2 Flow pager, sometimes it's surgical, sometimes 18 it's radiology. But there is a staff that's 19 always on the pager and available in an acute 20 situation. 21 Q. And does that refer to a call being made 22 to the 2 Flow team? 23 A. I believe so. I couldn't really comment 24 on that because I would not have been involved in 25 that. 0010 1 Q. Who would have been involved in making 2 the call to, as is noted here, the stroke 3 fellow/staff? 4 A. So that would have been the senior 5 resident for that evening. 6 Q. All right. Do you have any independent 7 recollection, aside from what is charted in this 8 patient's record, of the senior resident having a 9 conversation with the stroke fellow or staff? 10 A. In fact, I do. I know that as soon as 11 we had finished our assessment we had run to take 12 the patient down to get emergent imaging, and 13 while we were actually in the imaging scanner the 14 senior resident for the evening was on the phone 15 having a fairly extensive conversation with the 16 staff. 17 Q. Okay. And you have an independent 18 recollection of that? 19 A. I recall them having a conversation. 20 What was said in the conversation, I really 21 couldn't comment on. 22 Q. Who was the staff member and who was the 23 senior resident involved by your recollection in 24 that conversation? 25 A. I could tell you that the senior 0011 1 resident was Dr. Bermel. I do not know who the 2 staff was on the other end of the phone call that 3 evening. 4 Q. And I apologize if I asked this, but 5 just to clarify, would the staff member have been 6 someone from the 2 Flow service as opposed to the 7 2 Clot service? And if you don't know, tell me 8 that as well. 9 A. It could have been either. 10 Q. Do you know? 11 A. No, I don't know who was on call that 12 night so I couldn't tell you whether or not they 13 were a part of the 2 Clot or the 2 Flow team. 14 There are members that are on both teams 15 simultaneously, so I couldn't tell you for sure 16 who that would be. 17 Q. And it was my understanding from earlier 18 depositions -- and tell me if I have this wrong, 19 but that the staff for the 2 Clot team would make 20 decisions with respect to IV thrombolytics to 21 treat a stroke, and the staff from the 2 Flow 22 team would make a decision with respect to 23 intraarterial administration of thrombolytics to 24 treat an acute stroke. Is that correct? 25 A. To the best of my knowledge, that's 0012 1 accurate. 2 Q. And just so I'm clear, would it be the 3 case based on what you have charted here that 4 only one or the other of those services was 5 contacted, meaning either the 2 Clot attending 6 was consulted with or the 2 Flow attending was 7 consulted with? 8 A. So I wouldn't be able to comment on this 9 particular scenario, but what I could tell you 10 from other experience is that oftentimes the two 11 different staff members will communicate with 12 each other regarding a particular case. 13 So although we may have contacted the, 14 you know, 2 Flow pager, that person may then 15 contact the person that's on call for the 2 Clot 16 team as well. 17 So there's a communication that goes on 18 between staff members. 19 Q. Okay. And then in here you -- below 20 that stroke fellow/staff page portion of your 21 assessment and plan, you state, "Initial 22 assessment - Patient candidate for TPA and 23 possible intervention." 24 Let me ask you with respect to that, was 25 that some -- was that a determination that you 0013 1 made or that Dr. Bermel made, or was it a 2 determination that was made by you two 3 collectively, or was it a determination made by 4 you, along with input from the staff, at that 5 point in time? 6 A. So this initial assessment, meaning 7 based on our initial exam without having any sort 8 of radiographic evidence or any knowledge of what 9 the size of the stroke was, this was strictly 10 based on the time course. 11 Q. And then below that it says, "Based on 12 relative match of DWI and PWI, TPA unlikely to be 13 helpful and risks deemed to outweigh benefits." 14 Let me ask you about that. The first 15 question I have is: Was this a determination 16 that would have been made by you, by you and 17 Dr. Bermel, or by you after staff input? 18 A. So this is a decision that is almost 19 exclusively always made on the basis of staff. 20 This would not have been something that 21 Dr. Bermel or myself had come to on our own. 22 Q. All right. And my next question is, 23 what does that mean, "Based on relative match of 24 DWI and PWI, TPA unlikely to be helpful?" 25 A. So it's been a number of years since 0014 1 I've been doing stroke. This is a little bit 2 outside my area of expertise. But my limited, 3 you know, ability to explain it at this point is 4 basically that there are different parameters for 5 looking at viable brain and you look basically to 6 see whether or not there is part of the brain 7 that's not dead, that's salvageable. 8 And so based on this kind of -- these 9 parameters, this diffusion and the perfusion, 10 there was no area of brain that was salvageable. 11 All of the brain that was undergoing stroke was 12 already dead and, therefore, there would have 13 been no benefit to reintroducing blood flow. 14 Q. Okay. In preparation for today's 15 deposition did you go back and review any records 16 other than your note? 17 A. I had the opportunity to review 18 Dr. Bermel's deposition and Dr. Abou-Chebl's 19 deposition. 20 Q. And was there anything in either of 21 those depositions that varies from your 22 recollection of events or varies from your 23 opinions about the care and treatment of 24 Mr. Sullivan? 25 A. I can tell you that Dr. Bermel's 0015 1 deposition is the one that I actually kind of 2 read through. I glazed through Dr. Abou-Chebl. 3 Just looking back at what Dr. Bermel had 4 recalled, I agree with everything that he had 5 laid out in his questioning session. 6 Q. Okay. Did you have a chance to review 7 anything else in terms of, say, films or any 8 other materials in preparation for today's 9 deposition? 10 A. No. 11 MR. KULWICKI: Okay. Doctor, thank you 12 for your time. That's all the questions I have. 13 Were you able to hear me well enough and 14 did I give you an opportunity to answer? 15 THE WITNESS: Yes, sir. 16 MR. KULWICKI: Okay. Well, thank you 17 and I'm done. 18 And, Anna, if you want to advise her 19 with respect to signature. 20 MS. CARULAS: Okay. You have the right 21 to read over the transcript and make sure 22 everything has been taken down accurately, but 23 this was so short and brief I don't think it's 24 necessary, so we'll waive that. 25 THE WITNESS: That's fine. 0016 1 MR. KULWICKI: Okay. Take care. 2 3 (Deposition concluded at 6:20 p.m.) 4 - - - - - 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0017 1 CERTIFICATE 2 3 The State of Ohio, ) 4 ) SS: 5 County of Cuyahoga. ) 6 7 I, Christine Leisure, a Notary Public within and for the State of Ohio, duly 8 commissioned and qualified, do hereby certify that the within named witness, JULIA TOUB, M.D., 9 was by me first duly sworn to testify the truth, the whole truth and nothing but the truth in the 10 cause aforesaid; that the testimony then given by the above-referenced witness was by me reduced to 11 stenotypy in the presence of said witness; afterwards transcribed, and that the foregoing is 12 a true and correct transcription of the testimony so given by the above-referenced witness. 13 I do further certify that this 14 deposition was taken at the time and place in the foregoing caption specified and was completed 15 without adjournment. I do further certify that I am not a relative, counsel or attorney for either 16 party, or otherwise interested in the event of this action. 17 IN WITNESS WHEREOF, I have hereunto set 18 my hand and affixed my seal of office at Cleveland, Ohio, on this _______ day of 19 ___________________________ , 2010. 20 21 22 _______________________________________ 23 Christine Leisure, Notary Public within and for the State of Ohio 24 My commission expires April 21, 2012 25 0018 1 SIGNATURE OF WITNESS 2 3 4 5 6 The deposition of JULIA TOUB, M.D., was taken 7 in the above-captioned matter on the date, time 8 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