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Transcript of MARC S. ITSKOWITZ, M.D., FACP, VOLUME 1

Date: January 7, 2015

Case: JOHNSON, ET AL. v. SAINT AGNES HEALTHCARE, ET AL.

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DEPOSITION OF MARC S. ITSKOWITZ, M.D., FACP, VOLUME 1CONDUCTED ON WEDNESDAY, JANUARY 7, 2015

888.433.3767 | WWW.PLANETDEPOS.COMPLANET DEPOS

1 (Pages 1 to 4)

1

1 IN THE CIRCUIT COURT FOR BALTIMORE CITY, MARYLAND

2 ---------------------------------x

3 BRIDGETT JOHNSON, Individually *

4 and as Personal Representative *

5 Of the Estate of KAREEM JACOBS, *

6 and *

7 ERNEST JACOBS, Individually * Case No.:

8 and as Father and Next Friend of * 24-C-13-008166

9 KAREEM M. JACOBS, *

10 Plaintiffs, *

11 v. *

12 SAINT AGNES HEALTHCARE, INC. *

13 et al., *

14 Defendants. *

15 ---------------------------------x

16 VOLUME 1

17 Deposition of MARC S. ITSKOWITZ, M.D., FACP

18 Pittsburgh, Pennsylvania

19 Wednesday, January 7, 2015, 5:05 p.m.

20 Job No.: 73107

21 Pages: 1 - 197

22 Reported by: Toni S. Myers

2

1 Deposition of MARC S. ITSKOWITZ, M.D., FACP,

2 held at the offices of:

3

4

5 MARC S. ITSKOWITZ, M.D., FACP

6 1307 Federal Street

7 Pittsburgh, Pennsylvania 15212

8 (412) 359-3895

9

10

11

12

13 Pursuant to Notice, before Toni S. Myers,

14 a Court Reporter and Notary Public in and for

15 the Commonwealth of Pennsylvania.

16

17

18

19

20

21

22

3

1 A P P E A R A N C E S2 On behalf of the Plaintiffs:3 Thomas Summers, Esquire4 Gilman & Bedigian LLC5 108 W. Timonium Road6 Suite 2037 Timonium, Maryland 210938 (410) 560-49999 (Present via telephone)

10

11 On behalf of the Defendant Saint Agnes 12 Healthcare, Inc.:13 Shannon Madden Marshall, Esquire14 Goodell, DeVries, Leech & Dann, LLP15 20th Floor16 One South Street17 Baltimore, Maryland 2120218 (410) 783-400019 (Present via telephone)20

21

22

4

1 A P P E A R A N C E S C O N T I N U E D

2 On behalf of the Defendants Jehangir Meer, M.D.,

3 Jon D. Falck, M.D., and Laura M. Alton, PA-C:

4 Lynne B. Malone, Esquire

5 Anderson, Coe & King, LLP

6 7 St. Paul Street

7 Suite 1600

8 Baltimore, Maryland 21202

9 (410) 752-1630

10 (Present via telephone)

11

12 On behalf of the Defendants Mateen A. Awan, M.D.

13 and Mateen A. Awan, M.D., LLC:

14 Trace G. Krueger, Esquire

15 Baxter, Baker, Sidle, Conn & Jones, P.A.

16 120 E. Baltimore Street

17 Suite 2100

18 Baltimore, Maryland 21202

19 (410) 230-3800

20 (Present via telephone)

21

22



2 (Pages 5 to 8)

5

1 C O N T E N T S

2 EXAMINATION OF MARC S. ITSKOWITZ, M.D., FACP PAGE

3 By Ms. Madden 6

4 By Ms. Malone 127

5

6

7 E X H I B I T S

8 (Attached to transcript)

9 ITSOWITZ DEPOSITION EXHIBIT PAGE

10 Exhibit 1 CV 8

11 Exhibit 2 Letter 35

12 Exhibit 3 Invoices 36

13 Exhibit 4 List of Expert Depositions 47

14

15

16

17

18

19

20

21

22

6

1 P R O C E E D I N G S

2 MARC S. ITSKOWITZ, M.D., FACP,

3 the deponent, having been first duly sworn, was

4 deposed and testified as follows:

5 EXAMINATION

6 BY MS. MADDEN:

7 Q. Doctor, can you please state your full

8 name and your current business address.

9 A. Marc Itskowitz, 1307 Federal Street,

10 Pittsburgh, PA 15212.

11 Q. And you've been deposed before; correct?

12 A. Yes.

13 Q. How many times?

14 A. Approximately 20 times.

15 Q. Knowing that you're familiar with the

16 process, I won't belabor the guidelines but just

17 like for your other depositions, wait until I

18 finish my question and I'll wait until you finish

19 your answer before I ask another one, so that we

20 don't, as best we can, speak over each other. Is

21 that agreeable?

22 A. Yes.

7

1 Q. If you answer a question, I will assume

2 that you have understood it. Is that also

3 agreeable?

4 A. Yes.

5 Q. If you need me to clarify anything at any

6 time, just let me know. Okay?

7 A. Yes.

8 Q. And, likewise, if you need a break at any

9 time, I will gladly accommoate you. Okay?

10 A. Yes.

11 Q. Do you have a copy of your CV with you?

12 A. Yes, I do.

13 Q. I have a copy a CV that ends on page 11.

14 Does that sound right?

15 A. I'm not sure which version or updated copy

16 you have.

17 Q. I'm not sure, either. Sorry. That's why

18 I'm asking.

19 A. Would you like me to give the court

20 reporter my most recent updated CV?

21 Q. Why don't you tell me -- sure. I'll wait

22 for the court reporter to mark it.

8

1 (Deposition Exhibit 1

2 was marked for identification.)

3 COURT REPORTER: We're ready.

4 BY MS. MADDEN:

5 Q. Thank you.

6 Doctor, is Exhibit 1 your most recent and

7 up-to-date curriculum vitae?

8 A. Yes.

9 Q. Are there any publications or

10 presentations on Exhibit 1 that pertain to your

11 opinions in this case?

12 A. I have certain publications that pertain

13 to pulmonary embolism.

14 Q. Can you circle on Exhibit 1 and name each

15 one that you're circling, all of those relevant

16 publications, relevant to the issues in this case

17 anyway.

18 A. (Witness complies.) I'm finished.

19 Q. Can you name which items you circled.

20 A. Sure. There are two letters in the New

21 England Journal of Medicine. One is entitled

22 "Thinking Outside the Box".



3 (Pages 9 to 12)

9

1 Q. What page is this?

2 A. On my version, it's page two.

3 Q. Okay. I see it. 2006?

4 A. Yes.

5 Q. Thank you.

6 A. And on page three, there's a letter

7 entitled "Long-Term Term Anticoagulant Therapy"

8 from 2003.

9 Q. Any other publications that pertain to the

10 issues in this case?

11 A. No, I don't think so.

12 Q. What was your Thinking Outside the Box

13 letter?

14 A. I would have to pull it up to refresh my

15 memory, but I believe it had to do with pulmonary

16 embolism and making the diagnosis.

17 Q. That's the publication that if you don't

18 have it handy, you have access to it; correct?

19 A. Yes.

20 Q. Would you please provide a copy to

21 Mr. Summers or Mr. Bedigian so that they can in

22 turn provide a copy to us at a later date.

10

1 A. Yes.

2 Q. I appreciate that.

3 Q. And the same for long-Term Anticoagulant

4 Therapy, could you do the same?

5 A. Yes.

6 Q. Provide a copy?

7 A. Yes.

8 Q. Thank you.

9 Long-Term Anticoagulant Therapy would not

10 play a role in the facts of this case; correct?

11 A. The article in the letter has to do with

12 how to manage patients who have pulmonary

13 embolism, including patients who are in the

14 hospital. So, there are issues that are relevant.

15 Q. You don't have an opinion that Mr. Jacobs

16 required long-term anticoagulant therapy, do you?

17 A. Mr. Jacobs required anticoagulation for

18 his pulmonary embolism. If you're asking me how

19 long he required it for, we would say at least

20 three months and probably six months.

21 Q. That long term?

22 A. It depends on who's defining long term.

11

1 Usually long term would be beyond that, but I

2 would usually consider a hypercoagulable workup in

3 a patient with a pulmonary embolism. So I can't

4 fully answer your question.

5 Q. I understand. But, in any event, these

6 two items that you've identified were letters to

7 the editors that you wrote?

8 A. Yes.

9 Q. These are not peer-reviewed journal

10 articles that you you authored; correct?

11 A. They are peer-reviewed, but they're not

12 original articles. They would be letters

13 commenting on other articles in the New England

14 Journal of Medicine.

15 Q. Have you done any original research into

16 the field of pulmonary embolism?

17 A. No.

18 Q. Looking at your CV, at least the version

19 that I have, you graduated from Cornell in 1994;

20 correct?

21 A. Yes.

22 Q. And then you earned your medical degree

12

1 from Drexel in 1998?

2 A. Yes.

3 Q. Then, you did a residency in internal

4 medicine at Allegheny General Hospital; correct?

5 A. Yes.

6 Q. Since you graduated from medical school,

7 have you had privileges to practice at any

8 hospital other than Allegheny General?

9 A. No.

10 Q. I assume you hold a license in

11 Pennsylvania; correct?

12 A. Yes.

13 Q. Have you ever been licensed to practice

14 medicine outside of the State of Pennsylvania?

15 A. No.

16 Q. You are board certified in internal

17 medicine?

18 A. Yes.

19 Q. When did you become board certified in

20 internal medicine exactly?

21 A. I was initially board certified in 2001

22 and I recertified and am currently certified



4 (Pages 13 to 16)

13

1 through 2021.

2 Q. Thank you. Very good.

3 Looking at page one of the CV that I have,

4 it has Diplomate, American Board of Internal

5 Medicine, valid through 2011. Should that be

6 2021?

7 A. Yes. That has been updated to 2021.

8 Q. Very good.

9 Are you board certified in any other

10 specialty of medicine?

11 A. No.

12 Q. Are you board eligible in any other

13 specialty of medicine?

14 A. No.

15 Q. You are not board certified in emergency

16 medicine; correct?

17 A. Correct.

18 Q. You're not board certified in pulmonary;

19 correct?

20 A. Correct.

21 Q. Is there a board certification for

22 intensive care medicine?

14

1 A. Yes, there is.

2 Q. And that's not a certification that you

3 hold; correct?

4 A. That's correct.

5 Q. Can you tell me about your current

6 practice.

7 A. Yes. I am an internist. I practice both

8 in the office and in the hospital. I spend

9 approximately 12 to 15 weeks a year full time

10 rounding in the hospital, where I see patients who

11 are admitted either to my primary service or

12 patients admitted to other services in which I'm

13 consulted. I commonly see patients in the

14 emergency department. I receive phone calls at

15 home as a teaching attending for unreferred

16 medicine patients. And in addition to my hospital

17 work, I have an outpatient practice as well.

18 Q. I missed part of what you said, I

19 apologize. You said you get calls at home as the

20 teaching attending for...?

21 A. The unreferred or unassigned patients. In

22 other words, if a patient comes to the emergency

15

1 department and does not have an established

2 physician at the hospital, then I am on call to

3 receive a patient who would require admission.

4 Q. Is that year-round or is that within that

5 12 to 15 weeks per year when you're full time

6 rounding in the hospital?

7 A. For me, that would be within those 12 to

8 15 weeks.

9 Q. Outside of those 12 to 15 weeks, do you

10 take calls from the ED?

11 A. Yes.

12 Q. In what capacity?

13 A. Monday through Thursday, I would take

14 calls on my own established office patients who

15 are in the emergency department.

16 Q. That would be for purposes of admitting

17 your own patients to your service in the hospital?

18 A. Yes. Either admitting them or potentially

19 sending them home, depending on their clinical

20 condition.

21 Q. Sure, sure.

22 When you talked about the 12 to 15 weeks

16

1 per year that you spent full time rounding in the

2 hospital, you mentioned seeing patients in the

3 emergency department. That's during the 12 to 15

4 weeks per year period?

5 A. Yes.

6 Q. In what capacity are you seeing patients

7 in the emergency department during these 12 to 15

8 weeks a year?

9 A. If I'm called down to evaluate a patient

10 for admission or if one of my own patients comes

11 to the emergency department, I will go down to the

12 ER to see them.

13 Q. If you're called to the ED to see a

14 patient possibly for admission, what floor or unit

15 would the patient be admitted to?

16 A. That would depend on their clinical

17 condition. It can range from an observation bed

18 to an ICU bed.

19 Q. What are all the possible units or types

20 of beds that a patient whom you would personally

21 see in the ED could be admitted to?

22 A. It could be an observation area with



5 (Pages 17 to 20)

17

1 limited amount of intervention, it could be a

2 regular nursing floor, it could be a cardiac

3 telemetry bed with cardiac monitoring, it can be

4 an intermediate or step-down unit, or it can an

5 intensive care unit bed.

6 Q. So when you see patients in the ED to

7 admit to any of one of these types of beds or

8 units, are you admitting those patients to your

9 service where you would be the attending?

10 A. Yes.

11 Q. So you might be an attending in an ICU and

12 you might be an attending in a cardiac telemetry

13 unit, you might be an attending in an IMCU?

14 A. Yes.

15 Q. Are there intensivists at your hospital

16 who serve as attendings in ICU?

17 A. Yes.

18 Q. Would it only be your own established

19 patients who you would admit to your own service

20 as the attending in the ICU?

21 A. Not necessarily. It could be an

22 unreferred or unassigned patient, depending on the

18

1 patient's clinical condition. But I would say the

2 majority of the unassigned patients who go to the

3 ICU would be admitted to the intensivist's

4 service.

5 Q. When you say "unreferred patients", who do

6 you mean?

7 A. Patients that don't have an established

8 doctor at the hospital.

9 Q. Are there ever times when a patient comes

10 in through the emergency department in your

11 hospital and that patient is admitted to one of

12 these other levels of care or floors or beds that

13 you described but there's no room at the end, so

14 to speak, and the patient is what's called boarded

15 in the emergency department pending transfer?

16 A. Yes.

17 Q. How often does that happen, if you know?

18 A. I can't give you an exact number, but it

19 does happen fairly frequently, where patients are

20 waiting hours in the emergency department awaiting

21 a bed to open up.

22 Q. In your hospital, how does it work in

19

1 terms of the care of those patients, generally, if

2 you know, when they've been admitted to another

3 floor or service but they're physically boarded in

4 the ED awaiting transfer?

5 A. In general terms, it's a shared

6 responsibility between the emergency department

7 and the accepting medicine team to care for the

8 patient. If the patient's condition changes or

9 they become unstable, then the ER is certainly

10 expected to handle the majority of the care. It

11 just depends, really, on the patient's condition

12 and how long they've been in the ER.

13 Q. When you are full time at the hospital for

14 12 to 15 weeks out of the year, would you call

15 yourself a hospitalist, or what title would you

16 have in that time frame?

17 A. I would function as a hospitalist, but we

18 don't use that term in our hospital, because that

19 term is typically used for internists that are

20 full time year-round in the hospital.

21 Q. Are there full-time year-round

22 hospitalists at Allegheny General?

20

1 A. Yes.

2 Q. Are you doing something different when

3 you're there for those 12 to 15 weeks a year, or

4 are you sort of filling in for the hospitalist

5 service?

6 A. We're not filling in. They have their own

7 separate service.

8 Q. Okay. I'm trying to understand what you

9 do differs from what a hospitalist would do at

10 your hospital.

11 A. The difference is that in addition to

12 seeing unassigned or unreferred patients, we're

13 also admitting our own practice patients. And we

14 still have to continue to care for our office

15 patients. Even if we're not seeing them in the

16 office, I have to be in touch with my nurses and

17 handle the tasks that are in the electronic health

18 record.

19 Hospitalists typically work shifts. They

20 would do typically 12 to 15 shifts a month,

21 whereas we are full-time responsible for our

22 hospital patients during those weeks.



6 (Pages 21 to 24)

21

1 Q. Are there written policies at

2 Allegheny General concerning the care of patients

3 who have been admitted to another service that are

4 boarded in the ED?

5 A. I'm not sure.

6 Q. I assume you can find out?

7 A. I could try.

8 Q. How would you try?

9 A. How would I try. I would contact the

10 Chair of Medicine or Chief Medical Officer and

11 find out if we have written policies.

12 Q. If you do, could you please provide those

13 to Mr. Summers or Mr. Bedigian.

14 A. Yes.

15 MR. SUMMERS: Let me just say, I'm

16 not consenting to that. This is Tom Summers. But

17 I will certainly see if it's possible for him to

18 find those, and I'm not sure how they're directly

19 relevant but I'm not arguing with you right now as

20 that. I'll see what he can find and I'll let you

21 know. Certainly.

22 MS. MADDEN: I understand. Thank

22

1 you.

2 BY MS. MADDEN:

3 Q. Going back to this 12 to 15 weeks a year

4 when you're full time in the hospital, is that

5 9:00 to 5:00, or what is full time to you, what

6 are your shifts?

7 A. There's no specific time. I typically get

8 into the hospital early, usually 6:00 to 7:00 in

9 the morning, and I stay typically until 5:00 or

10 6:00 in the afternoon. But sometimes I'll come

11 back in the evening a second time, depending on

12 what's happening.

13 Q. How does a typical day go when you're

14 working this 12 to 15 week full-time shift at the

15 hospital?

16 A. I'm rounding on our patients, seeing all

17 of our patients, writing notes. I round with

18 house staff usually for at least two hours a day.

19 I have a separate service that's called our

20 consult service, in which I round with one or two

21 health staff members for consults, and that would

22 be typically what I'm doing.

23

1 Q. When you say "round on our patients", are

2 you part of a private practice group?

3 A. Yes. So the patients that I have to see

4 in the hospital would be three different types of

5 patients. Patients that come from our practice

6 that are admitted to the hospital; patients that

7 we are consulted on by other services, usually

8 surgeons; and, thirdly, it would be patients that

9 don't have a doctor, and we call those the

10 unassigned or unreferred patient.

11 Q. Are you ever dealing with unassigned

12 patients outside of those 12 to 15 weeks?

13 A. No.

14 Q. And the consult service, I think you

15 mentioned, would typically be for patients who are

16 admitted to a surgical service?

17 A. Yes.

18 Q. What other services, if any, would you

19 consult for?

20 A. Would we be consulted for, is that the

21 question?

22 Q. Yeah. You said there are three times

24

1 types of patients that you see; ones from your

2 practice, ones for whom you're providing

3 consultation, typically by surgeons, and

4 unassigned patients. And I'm just asking if there

5 are any other services other than the surgery

6 service for whom you might provide consultation in

7 that 12 to 15 week capacity?

8 A. Yes. We get consults from many different

9 services. Neurology, cardiology sometimes will

10 consult us. The bulk of consults come from

11 orthopedics and general surgery.

12 Q. Are there pulmonology consultants

13 generally available at Allegheny General?

14 A. Yes.

15 Q. And there are intensivists at Allegheny

16 General?

17 A. Yes.

18 Q. When you see patients from your practice

19 in the hospital, are they -- let's say you're on

20 your 12 to 15 week hospital rotation, are those

21 patients from your practice group necessarily

22 admitted to your service or might they be admitted



7 (Pages 25 to 28)

25

1 to a different service?

2 A. They would be admitted under me. There

3 are four or five different house staff services,

4 so they could go to any one of those house staff

5 services. But I would be the attending and I

6 would have to see the patient.

7 Q. Who's on the house staff service?

8 A. It's usually comprised of a senior

9 resident, two or three interns, and third and

10 fourth year medical students.

11 Q. If a patient who is not your own patient

12 comes into the emergency department at

13 Allegheny General and there's a decision that the

14 patient might have a pulmonary embolism, you would

15 not typically be the consultant called for that

16 problem; correct?

17 A. That's not necessarily true, because they

18 could wind up getting admitted to a different

19 service depending on how they presented. If they

20 primarily came in with symptoms of a PE and that

21 was the primary reason they were there, then we

22 would be the primary admitting doctor. But

26

1 sometimes patients get admitted to other services

2 and we're consulted.

3 Q. So if a patient in the ED at Allegheny

4 General is suspected of having a pulmonary

5 embolism, an internist is called, not a

6 pulmonologist or intensivist?

7 A. That's generally true, but it would depend

8 on the condition of the patient, how severe their

9 condition is, and whether they require ventilator

10 support or whether they can go to an area of the

11 hospital that does not require intensivists.

12 Q. How many times does that happen during

13 your 12 to 15 weeks a year where a patient who is

14 not a part of your practice group gets admitted to

15 you for the primary purpose of working up,

16 evaluating, diagnosing, and treating pulmonary

17 embolism?

18 A. I can't give you an exact number, but

19 pulmonary embolism is, unfortunately, a common

20 condition, and I would estimate that I would admit

21 in the range of 50 patients a year with pulmonary

22 embolism.

27

1 Q. Are you admitting 50 patients a year as an

2 internist working in the hospital full time and

3 these are unassigned patients, or are you

4 including the patients of your private practice

5 group who might be admitted to the hospital for

6 pulmonary embolism even when you're not doing your

7 12 to 15 weeks hospital rotation?

8 A. The 50 patients would be the patients that

9 I would admit. So that would include the

10 unassigned patients, as well as the private

11 patients of our office that are coming to my

12 service when I'm rounding.

13 Q. How many times a year are you called by

14 the ED about a patient who's suspected by the ED

15 to having pulmonary embolism?

16 A. That's a very frequent occurrence, I can't

17 give you an exact number.

18 Q. Give me a range.

19 A. I'm afraid I can't give you a range. It's

20 a very common condition. A patient who comes in

21 with chest pain or shortness of breath,

22 tachycardia, low oxygen saturation, those are all

28

1 common conditions that would likely trigger a

2 workup. So the number of suspected PE is very

3 high.

4 Q. You say "very high" confidently. Higher

5 than what -- 5, 20? Higher than what?

6 A. Higher than the number of patients who are

7 eventually diagnosed with pulmonary embolism. We

8 try to maintain a high index of suspicion so that

9 we don't miss cases of pulmonary embolism, but I

10 can't give you a number in terms of how many times

11 I'm called about a possible PE, because the number

12 is very high.

13 Q. I'm just talking about the times during

14 your 12 to 15 weeks out of the year that you would

15 be called by the ED about a patient who is

16 suspected of having a pulmonary embolism. I know

17 you said you admit 50 patients a year for that

18 problem or potential problem. So fewer than 50, I

19 assume, 50 times a year you are called by the ED

20 when you're doing your 12 to 15 weeks of hospital

21 rotation; is that fair?

22 MR. SUMMERS: I'm going to object to



8 (Pages 29 to 32)

29

1 the question. It's a little bit longwinded but,

2 Doctor, if you can answer it, go ahead.

3 A. I'm sorry, Counsel, I'm not sure I

4 understand your question. The number of times

5 we're called with suspected PE is far more than

6 the number of times we admit patients with

7 pulmonary embolism.

8 Q. I see. So the 50 patients a year are the

9 number of patients you admit to go on to have

10 confirmed PE?

11 A. Yes. And please keep in mind that's an

12 approximate number.

13 Q. I am keeping that in mind. That's fine.

14 I'm not asking you to go through old medical

15 records but that's a fair approximation.

16 How about patients with new onset seizure,

17 how often are you called by the emergency

18 department to evaluate or admit or potentially

19 admit a patient with a chief presenting complaint

20 of new seizure?

21 A. Again, I can't give you an exact number,

22 but it's a fairly common condition that we workup

30

1 in internal medicine. If they don't go to

2 neurology, and they often don't, then they will

3 come to our service, internal medicine. I would

4 say where somewhere in the range of 50 to 100

5 patients with a seizure would be admitted to my

6 service.

7 Q. How does it work if you've gone home from

8 your shift at the hospital during this 12 to 15

9 weeks and you get a call late at night for a new

10 seizure patient, how does it work in terms of your

11 involvement at the time of that call?

12 A. Just to clarify, I don't have a shift, so

13 when I'm on, there no on or off during those

14 weeks. If I'm at home and I would get paged, I

15 would call back and find out what's happening with

16 the patient, ask the ER about specific

17 information. I also can log onto the electronic

18 health record from home and review the information

19 and make a decision whether or not I need to come

20 back into the hospital or whether the house staff

21 can admit the patient and I'll see the patient in

22 the morning.

31

1 Q. are you speaking with an emergency

2 department physician during this call?

3 A. Yes.

4 Q. Do you rely on that physician to give you

5 clinically significant information about the

6 patient?

7 A. I'm not sure what you mean by "rely on".

8 I listen to what they have to say. I often will

9 ask specific questions to find out what the

10 patient's vital signs are. And very often I will

11 log onto the electronic record and review it

12 myself.

13 Q. How long have you had the ability to log

14 onto the electronic record and review it from

15 home?

16 A. I don't know the exact number, but it's

17 been at least four or five years, maybe longer.

18 Q. Do you know that you had that ability in

19 August of 2011?

20 A. Yes, I did.

21 Q. Do you know if there would be the ability

22 to remotely log on and review electronic medical

32

1 records at Saint Agnes in in 2011?

2 A. No.

3 Q. When you make a decision about whether the

4 house staff can admit the patient and you can see

5 the patient in the morning or whether the patient

6 requires admission at all, what in general are you

7 evaluating during this call?

8 A. I'm trying to get a general sense as to

9 how stable or unstable the patient is. I will

10 often ask the ER to provide me vital signs and

11 laboratory data and imaging data and I use that to

12 try to make a decision as to whether the patient

13 needs to be admitted, and if so, where they should

14 should be admitted to.

15 Q. So, you're never the attending physician

16 in an emergency department; is that fair?

17 A. Correct.

18 Q. You never served in that capacity in your

19 career as an internist; correct?


21 Q. I'm going to go back and ask you some

22 logistical questions. What materials have you



9 (Pages 33 to 36)

33

1 brought with you today?

2 A. I basically brought my file in the case,

3 which would include the medical records from St.

4 Agnes Hospital, the records from Baltimore Fire

5 EMS, the Plaintiffs preliminary designation of

6 expert witnesses, the deposition transcript of

7 Bridgett Johnson, Ernest Jacobs, Mateen Awan,

8 Dr. Meer, Dr. Falck, and the deposition transcript

9 of Laura Alton.

10 Q. Thank you.

11 Did you make any notes at any time in the

12 course of your review or discussions with Counsel?

13 A. The only notes I have are stick-it notes,

14 or post-it notes that are attached to the records.

15 Q. Do you have any writing on the post-its?

16 A. Yes.

17 Q. Can you just go through -- and I apologize

18 that I'm not there, I wanted to be there but my

19 car didn't cooperate this morning -- can you

20 please tell us what you've tabbed, and as you go

21 through those tabs, let us know what's written on

22 those post-its.

34

1 A. Yes. Starting with the medical records

2 from Saint Agnes Hospital, and this is starting on

3 page nine, I have a post-it note that I wrote

4 vitals 8-20-11 -- do you want me to tell you about

5 the post-it notes where I didn't write anything

6 on?

7 Q. Sure. I'm interested in knowing what

8 pages you tabbed. I assumed you tabbed pages that

9 were significant in some way to your review and

10 your opinions?

11 A. Yes.

12 MR. SUMMERS: How many are we talking

13 about, Doctor, because if that's going to be an

14 hour on this, we can probably just get you the

15 record, Shannon, and you'd know then.

16 MS. MADDEN: That's a good point.

17 A. There are a fair number of tabs.

18 MR. SUMMERS: What I'd be happy to

19 do, Shannon, is have him ship them to me or even

20 you and we can get them back to him in the same

21 form. And then you'd know for sure what he's

22 got.

35

1 MS. MADDEN: That sounds good to me.

2 BY MS. MADDEN:

3 Q. Were you provided with any correspondence

4 or case summaries from Plaintiffs' counsel in this

5 case?

6 A. No.

7 Q. Do you have any correspondence at all?

8 A. The only correspondence I would have would

9 be, basically, a cover letter from Attorney

10 Bedigian saying he's enclosed the medical

11 records.

12 Q. What's the date of that letter?

13 A. That letter does not have a date on it.

14 MS. MADDEN: Could you mark that as

15 Exhibit 2.

16 COURT REPORTER: Yes.



19 BY MS. MADDEN:

20 Q. Was the first time you got the medical

21 records was, I guess, with that letter marked as

22 Exhibit 2?

36

1 A. Yes.

2 Q. Do you know when that was?

3 A. Yes. That was in July of 2014.

4 Q. How is it that you know that?

5 A. Because I noted that on my invoice to the

6 attorney.

7 Q. Do you have a copy of any invoices that

8 you generated in this case?

9 A. Yes.

10 Q. How many are there?

11 A. There are two.

12 Q. Could we make those collectively

13 Exhibit 3, please.

14 A. Yes.



17 A. Okay.

18 Q. Doctor, what are your current fees for

19 reviewing testimony?

20 A. My fees are $350 an hour to review records

21 and $700 an hour for deposition and trial

22 testimony.



10 (Pages 37 to 40)

37

1 Q. How much time have you put into this case

2 so far, if you can tell from your invoices?

3 A. The first invoice was 3.75 hours and the

4 current invoice is 12.5 hours.

5 Q. At this point have you reviewed all of the

6 medical records that you described having

7 received?

8 A. Yes.

9 Q. And have you reviewed all the depositions

10 that you've received?

11 A. Yes.

12 Q. Did you make any notes on the depo

13 transcripts?

14 A. Yes, I did. The same format, with the

15 post-it notes on the sides.

16 Q. Did you put any commentary on the post-it

17 notes in connection with your review of the

18 deposition?

19 A. Yes.

20 Q. How many are there?

21 A. There are approximately three or four per

22 deposition.

38

1 Q. I'm just going to ask you what, if

2 anything, you commented on in the depositions of

3 Mr. Jacobs and Ms. Johnson?

4 A. For Mr. Jacobs' deposition, I actually

5 have no post-it notes or comments.

6 Q. Okay.

7 A. For Bridgett Johnson, I have approximately

8 five or six. Would you like me to read them?

9 Q. Actually, no. I'm going to switch gears

10 and ask you if you've done any literature reviews

11 in the course of your work in this case?

12 A. No.

13 Q. You didn't get on PubMed or any other

14 medical website to look up any of the issues in

15 this case?

16 A. No.

17 Q. Were you provided with any medical

18 literature from the Plaintiffs' attorneys?

19 A. No.

20 Q. Have you consulted with any other health

21 care providers about your opinions in this case?

22 A. No.

39

1 Q. Do you know Bruce Charash?

2 A. No.

3 Q. Do you know Dr. Lisbon?

4 A. No.

5 Q. Doctor, you mentioned having a designation

6 of expert witnesses filed by Plaintiff in this

7 case, is that a complete designation or just the

8 portion that mentions you?

9 A. I have a ten-page document which mentions

10 the other physicians as well.

11 Q. As you've looked through that document, do

12 you know any of the other experts designated?

13 A. No, I don't.

14 Q. When was the first time you saw or

15 received that document?

16 A. That document I reviewed on July 21, 2014.

17 Q. And do you know that because you listed it

18 in your invoice?

19 A. Yes.

20 Q. Did you have any input in preparing that

21 document?

22 A. No.

40

1 Q. Do you have a copy of the notice for your

2 deposition?

3 A. I have a letter from Attorney Bedigian

4 dated December 17, confirming the date of the

5 deposition. I don't know if, legally, that's

6 considered a notice or not.

7 Q. I'm actually talking about something a

8 little more formalistic. I thought you mentioned

9 you just had the one undated letter enclosing

10 medical records. Is there any other

11 correspondence that you have or that you've

12 received at any time from Plaintiffs' attorney's

13 other than the December letter and the undated

14 cover letter with the records?

15 A. No. Besides the one from December 17

16 saying that the deposition would be today. I

17 didn't receive a formal notice.

18 Q. That's okay. We can walk through the

19 notice.

20 How about any e-mail correspondence, did

21 you exchange any e-mails with Plaintiffs' counsel?

22 A. No.



11 (Pages 41 to 44)

41

1 Q. The notice for your deposition tonight

2 asks you to bring certain materials and I'm just

3 going to go through the notice and go through the

4 materials that you've brought.

5 Number one asks for current CV and

6 bibliography, and I think we've covered that in

7 Exhibit 1; fair?

8 A. Yes.

9 Q. Number two asks for documents, films,

10 radiology, or imaging studies, records, or any

11 other materials of any nature that were supplied

12 to you or reviewed by you in connection with your

13 work in this case. And then it goes on to include

14 statements of witnesses, such as deposition

15 testimony, etc.

16 Have you identified for us already all of

17 the material that you have reviewed in this case?

18 A. Yes.

19 Q. Did you review any radiology studies?

20 A. I have not directly reviewed the study,

21 but I have reviewed reports of the study.

22 Q. The reports that would be in the patient's

42

1 chart as part of the medical record?

2 A. Yes.

3 Q. Number three asks for all notes, side

4 margins, computer entries or other documents

5 created by you in the course of your review.

6 Have you identified for us all of those

7 materials that you've created in the course of

8 your review already?

9 A. Yes.

10 Q. Number four asks for all reports,

11 correspondence, including phone messages, letters

12 faxes, e-mails or other correspondence to or from

13 you and Counsel for Plaintiff.

14 Have you identified all of those

15 materials?

16 A. Yes.

17 Q. Number five asks for all medical or

18 economic literature of any nature, kind or

19 description read, reviewed relied upon or

20 consulted by you, and the answer to that is

21 "none"; correct?

22 A. Correct.

43

1 Q. Number six asks for documents of any

2 nature, kind or description reflecting time spent

3 reviewing this case, and those are the two

4 invoices that we've already marked as, I think, 2

5 or 3?

6 A. Yes. Exhibit 3.

7 Q. Thank you.

8 Number seven asks for all notes or reports

9 that you've generated -- I'm getting a little

10 redundant, as you can tell -- you've already told

11 us all of those; correct?

12 A. Yes.

13 Q. Number eight asks for 1099s and tax

14 returns showing the amount of income earned from

15 medical-legal activity over the last five years.

16 Have you brought that?

17 A. No.

18 Q. How much did you earn not as a percentage

19 of your total income but in dollar amount in 2014

20 from medical-legal activity?

21 A. I'm not sure of the exact number.

22 Q. I'm not asking for an exact number but

44

1 just an educated estimate.

2 A. I would estimate somewhere in the range of

3 $50,000 to $75,000 would be the range. But,

4 again, I don't know the exact number for 2014.

5 Q. Has that rough $50,000 to $70,000 range

6 been about the same in the past five years?

7 A. Yes.

8 Q. Have you ever earned as much as $100,000

9 from medical-legal activity?

10 A. No.

11 Q. Over the past, let's say, two to three

12 years, can you break down how your expert work has

13 been divided among or between plaintiffs and

14 defendants?

15 A. I don't know the exact breakdown. I would

16 say in the last two to three years, it's probably

17 been fairly evenly split between plaintiff and

18 defense, but I don't know the exact number.

19 Q. How many times have you testified at

20 trial?

21 A. Approximately five to ten times.

22 Q. Of those five to ten trial appearances,



12 (Pages 45 to 48)

45

1 how many have been for plaintiffs versus

2 defendants?

3 A. Most of them have been for defendants, but

4 I have testified approximately two or three times

5 for plaintiff at trial.

6 Q. Can you name any attorneys in the

7 Maryland/D.C./Virginia D.C. Area whom you've

8 worked for either on behalf of a plaintiff or a

9 defendant?

10 A. Off the top of my head, Attorney Bedigian,

11 a Mike Sanders, and Mark Cohen would be three that

12 come to mind.

13 Q. Mr. Bedigian and Sanders would be

14 plaintiffs' lawyers; correct?

15 A. Yes.

16 Q. How about Mark Cohen?

17 A. Also a plaintiff attorney.

18 Q. When was the last time you testified at

19 trial?

20 A. I testified at trial, I believe the last

21 time was in November.

22 Q. Of 2014?

46

1 A. Yes.

2 Q. That was for a plaintiff?

3 A. No. That would be for a defense.

4 Q. What attorney hired you?

5 A. I believe it was an attorney here in

6 Pittsburgh, Ron Puntil, P-U-N-T-I-L.

7 Q. What type of case?

8 A. I don't remember the details of the case,

9 but I can get back to you on that if you'd like.

10 Q. Do you keep copies of the deposition

11 transcripts that you give as an expert witness?

12 A. No.

13 Q. Do you have a list of trials and

14 depositions that you've given as an expert

15 witness?

16 A. Yes, I do have a list like that.

17 Q. Did you bring that with you?

18 A. Yes.

19 Q. That's covered by No. 11 of the notice, by

20 the way. Can we mark that as the next exhibit,

21 please.

22 A. Yes.

47

1 Q. Thank you.



4 A. Okay. We're ready.

5 Q. Just to complete going through the notice

6 here, number nine asks for deposition transcripts

7 of testimony you've given as an expert witness or

8 as a fact witness. Am I correct that you do not

9 have those?


11 Q. Even for any open and pending cases, you

12 don't have any copies of your deposition

13 testimony?

14 A. Actually, I would like to clarify. For

15 open cases, I probably do have those, but I

16 wouldn't keep any old cases.

17 Q. Do you have any open cases that deal with

18 the issues of pulmonary embolism?

19 A. No, I don't think so.

20 Q. Of your open cases, do you have a sense of

21 whether they're for plaintiffs or defendants?

22 A. I'm not sure. Sometimes I would be asked

48

1 to review a case and don't hear back from the

2 attorney for a long time. Sometimes I'm not even

3 told whether the case is still open or whether it

4 was settled.

5 Q. How many open cases do you have, as far as

6 you know?

7 A. Like I said, they sometimes don't even

8 tell me if it's open or close. But as far as I

9 know, there's probably five cases that are open.

10 Q. Do you have a written fee schedule?

11 A. Yes.

12 Q. Do you have a copy with you?

13 A. I did not bring one to the conference

14 room, but I can send that to you if you would

15 like.

16 Q. That would be great. If you could supply

17 a copy to Mr. Summers or Mr. Bedigian and one of

18 those two gentlemen can circulate it to us. That

19 would be helpful. It's covered by No. 10 of the

20 notice.

21 A. I'll take care of that.

22 Q. Thank you.



13 (Pages 49 to 52)

49

1 Do you charge a retainer?

2 A. No.

3 Q. Have you ever been sued before?

4 A. No.

5 Q. You've never been sued in your career?


7 Q. Were you sued in Allegheny County in the

8 matter of Gusic, G-U-S-I-C, versus Itskowitz,

9 M.D.?

10 A. That wasn't me.

11 Q. Okay. Any relation?

12 A. I'm not sure. Who's the first name?

13 Q. I'm not sure it'll be easily found. I

14 trust that you would know if you were sued,

15 Doctor.

16 When you get called by the emergency

17 department about a patient for possible admission,

18 is it the case that you're making the decision as

19 to whether or not to admit the patient or the

20 patient's already been admitted and you're

21 weighing in on where they go? What exactly is

22 your role, and I realize it might be different for

50

1 different scenarios.

2 How does it work when you called by the

3 emergency department about a patient who either is

4 being admitted or their admission is contemplated?

5 A. I'm involved in both of those scenarios

6 that you posed. Sometimes they will call me to

7 ask for my opinion on whether a patient needs to

8 be admitted. That's more typical if it's a

9 private patient of our office that we can

10 potentially see in the office very soon after that

11 ER visit. But I'm also called simply being told

12 that a patient needs to be admitted.

13 Q. And the question is, when you're being

14 told that the patient needs to be admitted, are

15 you being asked to admit the patient to your

16 service?

17 A. Yes. And what kind of care that I would

18 like or whether any additional tests needs to be

19 done or where the patient should be admitted to.

20 Q. I see.

21 For patients at Allegheny General who are

22 in the emergency department who have been admitted

51

1 to another floor or service but who are boarded in

2 the emergency department, does the emergency

3 department maintain the ability to order and carry

4 out tests on those patients.

5 MS. MALONE: I just object to the

6 form. It's Lynne Malone.

7 A. The answer is yes.

8 Q. Doctor, I just want to know if you're

9 going to offer any opinions at trial about the

10 patient's first visit to Saint Agnes for his ankle

11 injury?

12 A. Could you clarify, are you asking me am I

13 going to offer opinion about standard of care or

14 will it be --

15 Q. Yes. That's what I meant. Sorry,

16 Doctor.

17 A. No. I will not offer an opinion on

18 standard of care for the first ER visit.

19 Q. Looking at the Baltimore Fire EMS records

20 in this case, did you form an opinion as to the

21 cause of the patient's witnessed seizure or

22 seizure-like activity at home?

52

1 A. Are you asking me, did I form my opinion

2 solely based on the Baltimore Fire EMS records?

3 Q. Have you formed an opinion based on the

4 entirety of your review as to the cause of the

5 patient's witnessed seizure or seizure-like

6 activity at home before coming into Saint Agnes?

7 A. Yes.

8 Q. And what is that opinion?

9 A. The patient's seizure or seizure-like

10 activity was caused by cerebral hypoxia, or low

11 oxygen.

12 Q. From what?

13 A. From a pulmonary embolism.

14 Q. When did he first develop a pulmonary

15 embolism?

16 A. I can't give you the exact time, but my

17 opinion in this case is that his seizure-like

18 activity was caused by a pulmonary embolism.

19 Immediately prior to him being evaluated by EMS is

20 when he had that activity.

21 Q. I understand, I'm just wondering if you

22 have an opinion as to when before EMS was called



14 (Pages 53 to 56)

53

1 the patient had a pulmonary embolism.

2 A. I can't give you an exact time. They were

3 at the scene at 6:49 p.m., and sometime before

4 then, when the patient's mother noticed him to be

5 acting abnormally, is when he had his pulmonary

6 embolism.

7 Q. Was he throwing any pulmonary emboli prior

8 to the seizure-like activity witnessed by the

9 mother?

10 A. That's impossible to know, because you can

11 have subclinical pulmonary emboli that are

12 smaller, but there's no evidence that he had any

13 significant pulmonary emboli prior to the

14 seizure-like activity.

15 Q. Do you have an opinion as to how large the

16 clot was at the time of the seizure-like

17 activity? Should we call it seizure or

18 seizure-like activity, is it the same difference?

19 A. I think there is a distinction in terms of

20 whether it's a seizure or seizure-like activity,

21 but -- I'm sorry, what was your question?

22 Q. I apologize because I mixed and merged two

54

1 questions.

2 Did Kareem Jacobs have a seizure at home

3 in your opinion?

4 A. He either had a seizure or seizure-like

5 activity. The reason I'm suggesting there may be

6 a subtle distinction here is that when he was

7 evaluated by EMS, they noted him to be alert and

8 oriented times four. Typically seizures will

9 result in a prolonged postictal state. And

10 patients who develop acute pulmonary emboli can

11 develop seizure-like activity from cerebral

12 hypoxia. So he had seizure-like activity, but it

13 may not have been a full-blown seizure with a

14 traditional postictal confused state.

15 Q. What are the signs and symptoms of a

16 traditional postictal state?

17 A. Typically patients are nonresponsive for a

18 period of time and slow to respond for minutes,

19 sometimes as long as 30 minutes, following the

20 activity. It depends on what type of seizure the

21 patient experiences.

22 Q. Any other signs and symptoms of postictal

55

1 state other than patient being slow to respond for

2 up to 30 minutes?

3 A. They can have amnesia to the event. They

4 often have incontinency during or after the

5 event. Those would be the major postictal

6 findings.

7 Q. What about pulmonary embolism, what are

8 the signs and symptoms of pulmonary embolism?

9 A. There are many signs and symptoms of

10 pulmonary embolism. Some patients have no

11 symptoms. Some patient have shortness of breath,

12 chest pain, heart palpations, air hunger. They

13 may have findings on physical examination like

14 tachycardia, tachypnea. There's a whole range of

15 other signs or symptoms that are possible.

16 Q. Understanding that there are a whole range

17 that are possible, are there specific signs or

18 symptoms that you would typically expect to see in

19 a patient who has a pulmonary embolism?

20 A. No.

21 Q. Have you ever testified under oath that

22 you would expect shortness of breath in a patient

56

1 who has pulmonary embolism?

2 A. I'm not sure if I have.

3 Q. Would you expect shortness of breath in a

4 patient with a pulmonary embolism significant

5 enough to cause cerebral hypoxia and seizure-like

6 activity?

7 A. I would answer that in the following way

8 that generally the answer would be yes, but if a

9 patient has a pulmonary embolism severe enough to

10 cause altered mental status, then they may not

11 report shortness of breath either because they're

12 confused or they may not have time to report it.

13 Q. Are you going to offer an opinion at trial

14 in this case that Kareem Jacobs did not have time

15 to report any shortness of breath he might have

16 experienced during his admission at Saint Agnes

17 and before his code early in the morning of the

18 second second day of admission?

19 MR. SUMMERS: Objection. I'm not

20 sure what that means, but, Doctor, if you can

21 answer, go ahead.

22 A. I think that the patient did have time to



15 (Pages 57 to 60)

57

1 report it, certainly the patient's mother, in her

2 deposition transcript, stated that she didn't feel

3 he was breathing normally, but I do believe there

4 was time for him to report shortness of breath.

5 Q. Do the medical records reflect that

6 Mr. Jacobs reported shortness of breath to his

7 health care providers at any time before his code?

8 A. Not that I'm aware of, no.

9 Q. Do the records reflect that the patient

10 denied shortness of breath?

11 A. Yes.

12 Q. Do the records reflect that the patient

13 denied chest pain?

14 A. That's correct. He was reporting

15 fluttering in his chest but not chest pain.

16 Q. And you would expect pleuritic chest pain

17 in a patient with a pulmonary embolism significant


19 activity?

20 A. No. That would not be my expectation in

21 all cases.

22 Q. I didn't ask you if that's your

58

1 expectation in all cases. I'm asking you in a

2 patient who's got a pulmonary embolism significant


4 activity, would you expect that patient to have

5 pleuritic chest pain?

6 A. No. And the reason is that pulmonary

7 embolism is known as the great masquerader or the

8 great mimic. And each individual patient that has

9 a pulmonary embolism may or may not have a whole

10 host of signs or symptoms. So the answer would be

11 no. Unfortunately, it's not that easy to say that

12 every patient with a severe PE has to have

13 pleuritic chest pain.

14 Q. Would you expect that most patients with

15 severe PE would have pleuritic chest pains?

16 A. No.

17 Q. Have you ever testified for the defense in

18 a pulmonary embolism case that you would expect a

19 patient with a pulmonary embolism to have

20 pleuritic chest pain?

21 A. I don't know what I've testified in the

22 past specifically with other cases, but I don't

59

1 believe I've ever said that all patients with

2 pulmonary embolisms have to have pleuritic chest

3 pain. It's just one of many possible symptoms.

4 Q. Is it one of the symptoms you would expect

5 most patients with significant pulmonary embolism

6 to have?

7 A. I'm sorry, I didn't hear the question.

8 Q. Is it one of the symptoms, pleuritic chest

9 pain, that you would expect most patients with

10 significant pulmonary embolism to have?

11 A. I would answer you like this, Counsel.

12 It's a symptom that some patients with pulmonary

13 embolism have. I'm not sure if most patients have

14 pleuritic chest pain.

15 Q. Do you know what the internal medicine

16 literature says on that?

17 A. You referring to a specific article or a

18 series of articles or -- I'm not sure what your

19 question is.

20 Q. My question is, are you referring to or

21 relying on any specific internal medicine

22 literature or other medical literature to support

60

1 the position that pleuritic chest pain is not

2 typical with significant pulmonary embolism?

3 A. I'm not relying on any specific literature

4 for that answer, no. This is based on my clinical

5 experience. I've certainly reviewed literature in

6 the past during my training but not specifically

7 for this case.

8 Q. How would a pulmonary embolism cause

9 cerebral hypoxia and seizure-like activity?

10 A. A pulmonary embolism that occurs can cause

11 acute right heart strain and acute right heart

12 failure which can drop the patient's blood

13 pressure significantly to the point where the

14 brain is not receiving adequate perfusion and

15 oxygen. A pulmonary embolism can also cause an

16 arrhythmia that can also drop the blood pressure

17 and cause cerebral hypoxia.

18 Q. Are those two different mechanisms?

19 A. Yes. One would be an electrophysiologic

20 event where there's an arrhythmia. The other is

21 more of a circulatory collapse that occurs with an

22 acute pulmonary embolism.



16 (Pages 61 to 64)

61

1 Q. In this case, do you have an opinion as to

2 which of those two mechanisms occurred, if you

3 believe one occurred, to cause Mr. Jacobs to have

4 seizure-like activity?

5 A. It's hard to know for sure because we

6 don't have cardiac monitoring during his initial

7 event. But based on my review of the records,

8 it's most likely that he dropped his blood

9 pressure significantly enough to cause the

10 cerebral hypoxia.

11 Q. And he dropped his blood pressure, in his

12 opinion, from acute right heart strain and right

13 heart failure?

14 A. Yes.

15 Q. And that was caused by what exactly?

16 A. When the right side of the heart has to

17 pump against a pulmonary embolism in the lungs,

18 the right heart may not be able to compensate for

19 the increased pressure or workload and it cannot

20 perfuse the left side of the heart. And when the

21 left side of the heart does not receive enough

22 blood, that typically drops the blood pressure.

62

1 Q. Have you formed an opinion -- first of

2 all, let me back up. I'm sorry, Doctor.

3 When you first reviewed this case, you

4 understood that Mr. Jacobs had died; correct?

5 A. Yes.

6 Q. So before you finalized your opinions

7 about the standard of care, you knew the outcome

8 of the case; correct?

9 A. Yes.

10 Q. You're not board certified in cardiology;

11 correct?

12 A. Correct.

13 Q. You're not offering standard of care

14 opinions against any cardiologist in this case;

15 correct?

16 A. I'm not sure exactly the level of

17 involvement of the cardiologist in this case

18 because it's not clear to me from the records. It

19 appears that two cardiologist were consulted, one

20 for an abnormal EKG, one for positive cardiac

21 enzymes. If they were notified that the patient

22 was a young patient with a recent lower extremity

63

1 injury who was now presenting with tachycardia and

2 hypoxia, then they would be required to recommend

3 workup for pulmonary embolism.

4 Q. You've never served as a consulting

5 cardiologist in your career; correct?

6 A. Correct.

7 Q. Do you have an interventional cardiology

8 service at your hospital?

9 A. Yes.

10 Q. If you suspect that one of your patients

11 might need the service of interventional

12 cardiology, whom do you call?

13 MR. SUMMERS: A name or just a

14 service?

15 BY MS. MADDEN:

16 Q. I just mean a service or a title.

17 A. I would call whoever's on call for the

18 cardiology group.

19 Q. And whoever's on call for the cardiology

20 group would make a determination about whether

21 interventional services would be appropriate for

22 the patient?

64

1 A. That's generally true. Once a

2 cardiologist or a specialist from any area of

3 medicine is consulted, then they have a

4 responsibility towards the patient which may or

5 may not include a procedure.

6 Q. I'm just asking if when you call a

7 cardiologist on call to see if your patient needs

8 the services of interventional cardiology, the

9 person you're calling to let you know whether the

10 cath lab team will be activated or whether it's

11 not necessary; correct?

12 A. Not necessarily, no. If I'm contacting a

13 cardiologist, it may be a more broad opinion. It

14 may be a case like this, where you have a patient

15 who has an abnormal EKG, positive enzymes, and my

16 opinion is that once the cardiologist is

17 consulted, they're consulted as a physician, not

18 necessarily as an interventional proceduralist.

19 So they are involved in the care of the case.

20 Q. So, have you ever called an interventional

21 cardiologist just with giving the

22 interventionalist the EKG to read to see if the



17 (Pages 65 to 68)

65

1 cath teams needs to be activated for an acute

2 cardiac infarction or the like?

3 A. Yes.

4 Q. In that circumstance, the guidance that

5 you're seeking is do we need to get this patient

6 to the cath lab or not; right?

7 A. No. That's not what I said. I said the

8 guidance could include that, but it could also be

9 general guidance on how to care for the case.

10 Q. Because you yourself might not -- might

11 seek the expertise of someone with more experience

12 and training in cardiology to advise you on the

13 cardiac aspects of the care of the patient?

14 A. Yes.

15 Q. And there are times when what you expect

16 from the cardiologist might be just a limited

17 opinion and there are times when it might be a

18 broader opinion about the care of the patient, is

19 that what you're saying?

20 A. Yes.

21 Q. And you don't know specifically what the

22 conversation in this case was or the information

66

1 that was shared with the cardiologist in this

2 case; correct?


4 Q. Are you offering any opinion about the two

5 EKGs at issue in this case?

6 A. My opinion is that they were abnormal and

7 are a part of the thought process that there is

8 some abnormal process going on for that patient

9 that ultimately was found to be a pulmonary

10 embolism.

11 Q. Do you agree with me that an EKG alone is

12 not -- whatever it says is not diagnostic of a

13 pulmonary embolism; is that correct?


15 Q. You as an internist would not diagnose a

16 patient with a pulmonary embolism based on an EKG

17 alone; correct?


19 Q. There's no special EKG abnormality that

20 diagnoses pulmonary embolism?

21 A. Not 100 percent of the time. There is a

22 fairly specific pattern called an S1Q3T3 pattern

67

1 that if present on EKG is strongly suggestive of a

2 pulmonary embolism, but that pattern occurs in a

3 minority of patients with PE.

4 Q. And that pattern can occur in patients

5 without a PE; correct?

6 A. It can, but it certainly is the most

7 specific EKG finding for PE.

8 Q. But that's a different answer. S1Q3T3

9 pattern occurs in patients who do not have

10 pulmonary embolism; correct?

11 A. Yes.

12 Q. Do you know how to describe what an S1Q3T3

13 pattern is?

14 A. Yes.

15 Q. Do you believe that either of the two EKGs

16 in this case, if you're permitted to offer an

17 expert opinion in reading EKGs, demonstrate an

18 S1Q3T3 pattern?

19 A. They do not.

20 Q. I know you said that you believe his EKGs

21 were generally abnormal. Is it fair to say that

22 the second EKG improved compared to the first EKG?

68

1 Was the improvement in the EKGs from the first to

2 the second?

3 A. I guess I'd like to make sure I have the

4 right EKGs, I have them in front of me. There's

5 one August 20, 2011, at 1940, and then -- is the

6 second EKG referring to the one that immediately

7 follows in the records?

8 Q. It should be. It says sinus tachycardia,

9 otherwise normal EKG.

10 A. (Witness reviews document.) Okay, I see

11 that here. In terms of the ST elevation, it's

12 less prominent, but the heart rate has increased.

13 So, to answer your original question, I would say

14 both EKGs were abnormal and they both show

15 different things.

16 Q. I guess my question is -- and you can tell

17 me if you don't see it that way or you can't

18 answer it -- but is the second EKG improved as to

19 the first EKG?

20 A. No.

21 Q. What's the heart rate on the first EKG?

22 A. 96.



18 (Pages 69 to 72)

69

1 Q. And on the second?

2 A. 104 beats per minute.

3 Q. Did you read the first EKG as showing

4 early repolarization?

5 A. Early repolarization would be a

6 consideration. I would read it as normal sinus

7 rhythm with ST elevation, but you really can't say

8 specifically it's early repolarization. That's a

9 differential diagnosis term.

10 Q. What do you mean?

11 A. ST elevation on EKG can indicate

12 pericarditis or it can indicate an acute injury

13 pattern. Early repolarization is also a

14 consideration.

15 Q. Do you know if early repolarization can be

16 a normal anomaly in an African American young

17 male?

18 A. Yes, it can.

19 Q. Do you consider yourself an expert in EKG

20 interpretation?

21 A. I'm not sure what you mean by that.

22 Q. What's confusing?

70

1 A. Are you asking me an expert in a legal

2 sense or as an internist?

3 Q. Well, I'm just asking in a medical-legal

4 sense, do you consider yourself to be an expert in

5 interpreting EKGs, understanding that you're an

6 internist?


8 the form and foundation for the question. Doctor,

9 you can answer however you can. I think she's

10 asking do you interpret EKGs and do you feel you

11 have the expertise to do so.

12 A. Yes. I routinely order and interpret EKGs

13 and I've been doing it for many years and it's

14 part of my routine daily practice.

15 Q. In general, would you agree that board

16 certified cardiologists have greater training and

17 expertise in interpreting electrocardiograms?

18 A. That's a broad question, Counsel. I would

19 say they certainly get more training during their

20 fellowship. Some cardiologists only read EKGs all

21 day every day, other cardiologists read less of

22 them. But I think in general I would agree with

71

1 your statement that cardiologists get additional

2 training and expertise in reading EKGs.

3 Q. Meaning additional training above and

4 beyond what you've had?

5 A. Yes.

6 Q. Do you agree that there's no acute

7 coronary syndrome that's diagnosable from

8 Mr. Jacobs' EKGs?

9 A. You can't diagnose acute coronary syndrome

10 definitively from an EKG. If you have an injury

11 pattern, ST segment elevation on the first EKG,

12 you do have positive troponins which are

13 concerning for an injury pattern, you have sinus

14 tachycardia on the second one, which is the most

15 specific finding -- I'm sorry -- the most common

16 finding in pulmonary embolism. So, you really

17 need more data than just the EKG to answer that

18 question.

19 Q. My question was just about the EKG. Maybe

20 it was confusing and I apologize.

21 You agree that Mr. Jacobs' EKGs are not

22 diagnostic of acute coronary syndrome?

72

1 MR. SUMMERS: Objection. Asked and

2 answered. Doctor, you can go ahead.

3 A. They're not solely diagnostic. Keep in

4 mind, there is evolution of EKG findings in a

5 patient who presents with an acute coronary

6 syndrome, and ST segment elevation can be subtle

7 initially and it can change over time. I wouldn't

8 look at his initial EKG and think that a

9 19-year-old is having an acute coronary syndrome.

10 That would not be my first thought.

11 Q. Is it your last thought that he had an

12 acute coronary syndrome? In other words, at any

13 time did you form the opinion that this was an

14 acute coronary syndrome?

15 A. I don't believe he had any blockage of his

16 coronary arteries. I do believe that there was

17 cardiac involvement in this case secondary to his


19 Q. But that's not what you typically mean

20 when you use the term "acute coronary syndrome",

21 right, that's something distinct from pulmonary

22 embolism?



19 (Pages 73 to 76)

73

1 A. Generally, that's correct. Acute coronary

2 syndrome usually refers to an acute blockage of a

3 coronary artery.

4 Q. And you don't believe Mr. Jacobs had that

5 defect in this case?

6 A. That's correct. And that's why anyone

7 that was called on an EKG like this who was told

8 that there were positive enzymes should be

9 thinking pulmonary embolism and not acute coronary

10 syndrome.

11 Q. You don't know what any cardiologists were

12 specifically asked in this case; correct?

13 A. No. All I have is the medical records and

14 the deposition transcripts.

15 Q. In the medical records, if you could

16 please turn to Saint Agnes Hospital record that's

17 been referred to as a T Sheet. My pagination, I

18 think, might have been from Plaintiffs' Counsel,

19 it's page 31, but yours might be different. It

20 has differential DS in the top left and it says

21 number one, new onset SZ, in handwriting.

22 A. Yes, I have that page.

74

1 Q. Do you see where it says in the

2 handwriting, the top left -- and this is reviewed

3 in the deposition -- I'm not even going to pretend

4 to read what the first part says. I think it says

5 EKG send or fax or something to Dr. Dua, likely

6 BER, is that basic electric rhythm?

7 MS. MALONE: Objection to the form.

8 MR. SUMMERS: If you want to ask him

9 to accept that, I don't know that anyone will be

10 appropriate in the interpretation. But if you

11 wanted to ask him to accept that's what it says,

12 but I don't know that he should be --

13 MS. MADDEN: Tom, I don't have to.

14 BY MS. MADDEN:

15 Q. Actually, I'm just really getting to the

16 third line there that says not PAMI. Do you know

17 what PAMI to?

18 A. AMI is acute myocardial infarction.

19 Q. Do you agree that Mr. Jacobs did not

20 demonstrate acute myocardial infarction on his

21 EKGs?

22 A. Again, it was not a classic EKG pattern

75

1 for a myocardial infarction, but there was ST

2 elevation, which could be -- we can't use EKGs

3 alone in this case to figure out what's

4 happening. You really need to combine it with the

5 clinical history, the exam, and the labs.

6 Q. Even combining all those factors, you

7 don't believe Mr. Jacobs had an acute myocardial

8 infarction that explained his signs and symptoms,

9 do you?

10 A. By definition he had positive troponins,

11 so he did have myocardial infarction. I don't

12 believe he had a myocardial infarction solely on

13 the basis of a blockage in his heart. But with

14 two positive troponins there was cardiac damage

15 that would technically be a myocardial infarction.

16 Q. Let me ask a different question, then.

17 Just based on the EKGs, do you agree that they do

18 not diagnose acute myocardial infarction in this

19 case?

20 A. Counsel, I don't know if I'm not answering

21 it clearly, an EKG by itself can be nonspecific in

22 terms of myocardial infarction. In this case, we

76

1 have two EKGs. The first one shows ST elevation,

2 which could be a myocardial infarction. It could

3 be early repolarization. If you have an old EKG;

4 for example, from a few years earlier, that shows

5 early repolarization, that would suggest that

6 that's what you're dealing with in the current

7 situation. But the EKG alone is not enough

8 information to tell you whether or not the patient

9 is having a myocardial infarction.

10 Q. Can you sometimes get EKGs in patients

11 that are so abnormal that you believe based on the

12 EKG alone that they're likely having a myocardial

13 infarction?

14 A. Yes.

15 Q. And that's not the case in this instance;

16 correct?


18 MR. SUMMERS: I think it's time for a

19 break, Shannon.

20 MS. MADDEN: I'm sorry I've gone so

21 long without one. Yes, absolutely.

22 (Recess.)



20 (Pages 77 to 80)

77

1 BY MS. MADDEN:

2 Q. Doctor, hypothetically, just based on the

3 first EKG with no troponin levels back, would you

4 agree that that patient did not require activation

5 of the cath lab team?

6 A. Yes.

7 Q. From the records in the deposition

8 testimony you don't know what time there was a

9 second cardiology consult in this case; correct?

10 A. Yes.

11 Q. Do you have an opinion as to the cause of

12 Mr. Jacobs' low oxygen saturation on admission?

13 A. Yes. That was from his pulmonary

14 embolism.

15 Q. And after two liters of oxygen with nasal

16 cannula his oxygenation normalized?

17 A. Yes.

18 Q. If the patient had a PE that caused low

19 oxygen saturation, how would two liters of nasal

20 cannula cause the patient to revert to normal

21 oxygen levels?

22 A. The oxygen requirements after a pulmonary

78

1 embolism are based on at least two factors. One

2 would be the size of the pulmonary embolism. So a

3 smaller embolism would require less oxygen to

4 normalize. More importantly, it would be the

5 underlying cardiopulmonary state of the patient.

6 So, an otherwise young and healthy patient with a

7 pulmonary embolism could normalize his oxygenation

8 with as little as two liters of oxygen.

9 Q. Even with a massive PE?

10 A. Yes.

11 Q. Did Mr. Jacobs have a massive PE at the

12 time of his admission to Saint Agnes, in your

13 opinion?

14 A. Depending on how you define massive PE.

15 He had a significant PE that caused hemodynamic

16 changes and cerebral hypoxia. The term massive PE

17 is nonspecific. Usually we talk about saddle PE,

18 which occurred the following morning. So I don't

19 usually typically use the term massive PE.

20 Q. You've not used that word in testimony in

21 other PE cases?

22 A. I may have. I don't remember. I'm just

79

1 saying it's not a term that I typically use

2 clinically.

3 Q. Isn't there a term of art massive versus

4 submassive PE? Isn't that a recognized

5 distinction in the literature?

6 A. Yes.

7 Q. What is that distinction, at least as it's

8 used in the literature, if you know?

9 A. I believe it refers to hemodynamic changes

10 with, you know, changes in vital signs. Usually

11 the patient gets tachycardic, tachypnic, hypoxic

12 with a massive PE.

13 Q. So, you think that according to the

14 guidelines you believe Mr. Jacobs had a massive PE

15 at the time of his admission? If you don't know,

16 that's fine. I just want to know.

17 A. He certainly had those findings. In other

18 words, he had tachycardia and hypoxia. So if

19 we're using that definition, then, yes, he had a

20 massive PE.

21 Q. When did he first have a massive PE?

22 A. That would be when his mother discovered

80

1 him at home.

2 Q. When did he first have a saddle PE?

3 A. That would have been the following morning

4 when he went into cardiac arrest.

5 Q. I want to go to the time when the patient

6 was admitted after a phone call to Dr. Awan at

7 approximately 11:30 p.m. -- I'm skipping over the

8 rest of his care for the time being -- and ask you

9 what you believe the standard of care required at

10 that point.

11 A. The standard of care required that the

12 physicians order a CT scan of the chest on a stat

13 basis to rule out pulmonary embolism. The

14 standard of care would also require the

15 institution of anticoagulation if for some reason

16 they couldn't get the study done.

17 Q. So, ordering a stat CT and getting that

18 study physically done and the results back would

19 take up to how long with reasonably prudent care?

20 MS. MALONE: I'm sorry, Shannon,

21 after what time period?

22 MS. MADDEN: We're starting with the



21 (Pages 81 to 84)

81

1 proposition that this is after the call to

2 Dr. Awan at approximately 11:30 p.m.

3 MS. MALONE: Thank you.

4 MS. MADDEN: Sure.

5 A. I would say that within one hour it would

6 be reasonable to have a patient undergo a CT scan

7 and have it interpreted for a pulmonary embolism.

8 Q. And you understand that the patient was

9 still physically in the ED at this point; correct?

10 A. Yes.

11 Q. And when you say that the standard of care

12 requires the physician to order a stat CT scan,

13 who are you talking about?

14 A. I'm talking about any physician that was

15 involved in this case. The ER doctors, the

16 internist accepting the patient. This was a

17 systematic problem that -- all physicians were

18 responsible for the care of this patient.

19 Q. So after the call at 11:30, either an ER

20 doc or the consulting physician, in your opinion,

21 had to order a stat CT scan, or should have

22 ordered a stat CT scan to rule out PE?

82

1 A. Yes. Along with the accepting physician,

2 Dr. Awan.

3 Q. In the exercise of reasonable care, you

4 believe that result would have done -- the study

5 done, the result back within an hour?

6 A. Depending on the capability of

7 Saint Agnes, I would say within an hour is my

8 expectation. I think that would be consistent

9 with the standard of care.

10 Q. Do you have an opinion as to what that

11 CT scan would have shown?

12 A. Yes. The CT would have shown pulmonary

13 embolism.

14 Q. Saddle pulmonary embolism?

15 A. Not necessarily a saddle pulmonary

16 embolism, but it would have shown a pulmonary

17 embolism. And the treatment would have been blood

18 thinners.

19 Q. Specifically what?

20 A. Usually we start with IV Heparin. If

21 there was evidence of a right heart strain and the

22 patient's hemodynamics were unstable, then they

83

1 may have had to considered thrombolytic therapy.

2 Q. We have vital signs on the patient in the

3 early morning hours or after midnight; correct?

4 A. Yes.

5 Q. And do those vital signs show the type of

6 hemodynamic instability that would fit the

7 guidelines for TPA?

8 A. I would like an opportunity to just review

9 those, if that's okay.

10 Q. Absolutely, Doctor. I'm sorry, I forgot

11 to remind you, at any time if you need to review a

12 record or deposition testimony or just pause, just

13 let me know.

14 A. (Witness reviews documents.) Would you

15 happen to know the page that I could find those

16 vitals on?

17 Q. I should be able to tell you how it's

18 paginated in my set. It says page 276 at the

19 bottom right for vital signs that go up to

20 12:07 a.m. and 277, the one starts at 1:00 a.m.

21 A. Thank you. (Witness reviews documents.)

22 So, getting back to your question, he

84

1 certainly was tachycardic for many of these vital

2 sign recordings. His blood pressure by itself

3 would not qualify for TPA. It just depends on

4 what specific one you're looking at.

5 Q. We're talking about the hypothetical where

6 the CAT scan is done by 12:30 a.m. and you said

7 that the standard of care would require blood

8 thinners; namely, IV Heparin, and possibly TPA.

9 And I'm asking you to look at the vital signs we

10 have at this time around 12:30 or -- we've got

11 some at 12:07, I guess, tell us, if you know,

12 whether these vital signs meet the criteria for

13 administering TPA?

14 A. The vital signs by themselves do not. But

15 if you see evidence of right heart strain, and you

16 can see that on a CT scan, then that may be enough

17 to trigger the use of TPA and/or the further

18 diagnostic study, which would be a stat

19 echocardiogram.

20 Q. Do you have an opinion to a reasonable

21 degree of medical probability as to whether the

22 CAT scan under this hypothetical done on a stat



22 (Pages 85 to 88)

85

1 basis sometime between 11:30 p.m. and 12:30 a.m.

2 would have shown right heart strain sufficient to

3 meet TPA criteria or make the patient a candidate

4 for TPA?

5 A. I believe it would have, yes.

6 Q. What is that based on?

7 A. This patient presented initially because

8 of a significant hemodynamic event at home, which

9 was from cerebral hypoxia, and his vital signs

10 were abnormal in the ER, and the eventual CT scan

11 did show right heart strain. So based on that, I

12 believe it's likely that the CT done at this time

13 would have shown right heart strain.

14 Q. How so?

15 A. Again, I think he had a hemodynamically

16 significant pulmonary embolism that dropped his

17 blood pressure. And the mechanism, as we talked

18 about earlier, is pressure on the right side of

19 the heart, and there are signs on CT scan that

20 show strain of the right heart.

21 Q. Are you familiar with published criteria

22 for triggering the use of TPA to treat pulmonary

86

1 embolism?

2 A. I'm generally familiar with it. I'm aware

3 that there is generally a requirement for

4 hypotension. But I'm also familiar with the

5 guidelines or the recommendations that state that

6 if a patient drops their blood pressure, you can

7 consider TPA.

8 Q. What guidelines or recommendations are

9 those specifically?

10 A. Are you asking for a specific source?

11 Q. Yes?

12 A. I would have to review the medical

13 literature. I believe it's from the American

14 Heart Association or the American College of Chest

15 Physician Guidelines on thrombolytic therapy.

16 Q. Would you refer to a board certified

17 hematologist as to the criteria for TPA in a

18 patient like Mr. Jacobs diagnosed with pulmonary

19 embolism?

20 A. Did you ask about a hematologist?

21 Q. Yes.

22 A. The answer would be no. The hematologist,

87

1 in my experience, is not going to be involved in

2 that decision.

3 Q. How about an expert of thrombolytic

4 therapy, would you defer to an expert in

5 thrombolytic therapy as to whether a patient like

6 Mr. Jacobs likely would have been, or met the

7 criteria for TPA in this hypothetical?

8 A. I'm not sure what you mean by defer to a

9 thrombolytic expert. Typically, in clinical

10 practice, you may consult a cardiologist or a

11 pulmonologist in the setting of a PE. And

12 typically there would be discussion among the

13 physicians as to whether the patient would benefit

14 from TPA. But while there are indications for its

15 use, some of those indications are relative

16 indications, and every case is different.

17 Q. What are those relative indications?

18 A. Primarily it's hypotension, hypoxia, and

19 right heart strain.

20 Q. What specific vital signs after 12:30

21 a.m., if any, meet the TPA criteria of hemodynamic

22 instability for PE?

88

1 A. One of the vital signs would be heart

2 rate. We still have an elevated heart rate at --

3 it looks like seven minutes after midnight of

4 108. But, again, I'm not going to use a specific

5 vital sign alone to determine whether a patient

6 should get TPA for PE.

7 Q. Let me ask you this, can you tell me what

8 the specific guidelines either by the American

9 Heart Association or the American College of Chest

10 Physicians or any other medical body as of

11 August of 2011 in terms of criteria to give TPA in

12 a patient with PE?

13 A. Right heart strain would be the primary

14 criteria.

15 Q. Is there a threshold for the amount of

16 right heart strain that's required before a

17 patient needs TPA eligibility?

18 A. There's no absolute criteria. Right heart

19 strain in association with tachycardia or

20 hypotension would allow the patient to be a

21 candidate for TPA.

22 Q. Are you aware of whether there's a



23 (Pages 89 to 92)

89

1 suggestion not to use thrombolytics routinely in

2 patient with pulmonary embolism?

3 A. Certainly thrombolytics are not routinely

4 used for various reasons. Most pulmonary emboli

5 do not cause severe right heart strain to

6 necessitate the use of TPA. So, in general, we

7 don't use TPA to treat pulmonary embolism.

8 Q. How many times have you made the decision

9 as to whether or not to give TPA for a patient of

10 yours who has been diagnosed with pulmonary

11 embolism?

12 A. I can't give you an exact number, but it's

13 probably in the range of 30 or 40 patients in my

14 career, we've at least discussed it, and probably

15 given it maybe 10 or 15 times.

16 Q. When was the last time that you gave it

17 for a pulmonary embolism?

18 A. I think it's been a few years, but I don't

19 remember exactly when.

20 Q. Sitting here today, can you call up in

21 your mind a specific incident where you prescribed

22 TPA or ordered TPA for a patient of yours for

90

1 pulmonary embolism?

2 A. Yes.

3 Q. And when was that?

4 A. Like I said, I've done it many times. I

5 can remember cases where I was called to admit a

6 patient in the ER and they had abnormal vital

7 signs, right heart strain, typically I will

8 consult cardiology to see if they agree with my

9 decision. And then in that particular case that

10 I'm thinking about, we did move forward with TPA.

11 Q. Who orders the TPA in that circumstance?

12 A. In that circumstance, I ordered the TPA.

13 Q. How is it given?

14 A. Through the IV.

15 Q. What IV?

16 A. I'm not sure what you're asking. Usually

17 there's a central line and we give it as a bolus

18 and a drip. We have standard order sets that we

19 would use with the pharmacy.

20 Q. A bolus through a central line, not a

21 peripheral line?

22 A. Yes.

91

1 Q. Is there a standard dose in the bolus or

2 the drip?

3 A. Yes.

4 Q. What are those?

5 A. I don't remember the dose. I think it's

6 weight based. I don't remember the standard dose.

7 Q. You don't remember an algorithm for any

8 weight based dosing?

9 A. No.

10 Q. How long is it typically given, if you

11 know?

12 A. How long does it take to administer it?

13 Q. How long do you order a TPA for a patient

14 who's got a PE to be given? You said a bolus and

15 then a drip, how long -- are you looking for some

16 sort of clinical changes or lab results before you

17 stop it? Tell me how that works.

18 A. No. It's a standard protocol on how to

19 administer the TPA. I don't remember the specific

20 time frame over which the TPA is given, but

21 typically you're looking for a clinical response

22 in terms of improvement in hemodynamics.

92

1 Q. So if the patient stabilizes in terms of

2 vital signs?

3 A. Yes.

4 Q. Typically how long does that take, if you

5 know, from the time the TPA is started?

6 A. I've seen patients recover very quickly

7 after TPA is given.

8 Q. Have you seen patients die from pulmonary

9 embolism even after TPA is given?

10 A. Yes.

11 Q. Why does that sometimes happen?

12 A. Sometimes we've given TPA in a code

13 situation where a patient is given TPA in the

14 setting of a cardiac arrest, and in that case,

15 they die because the treatment that was instituted

16 was too late to save the patient.

17 Q. And sometimes patients die from a PE

18 despite being given TPA even when they haven't had

19 a terminal code -- I'm sorry -- even when they

20 haven't had a nonterminal code?

21 A. That is correct. But in my experience,

22 the majority of patients in whom you diagnose a



24 (Pages 93 to 96)

93

1 pulmonary embolism in a timely fashion and you

2 institute appropriate therapy, the majority of

3 patients will not die from the pulmonary embolism.

4 Q. In the 10 to 15 times in your career that

5 you've been involved with patients who were given

6 TPA for pulmonary embolism, how many lived and how

7 many died?

8 A. Most of them lived. The ones that died

9 usually died because they were already in cardiac

10 arrest when we gave TPA.

11 Q. Can you call to mind any of the clinical

12 circumstances any more specifically than you just

13 stated them?

14 A. I don't think so. I'm thinking about

15 cases that have occurred over the last 15 years,

16 so it's hard to really pull up specific details.

17 Q. So it occurs less than once a year, on

18 average, in the course of your career that you're

19 giving TPA to a patient for PE?

20 A. Yes. The majority of patients in whom we

21 diagnose PE will not receive TPA, but they will

22 receive appropriate anticoagulation therapy.

94

1 Q. And before you give TPA, you will consult

2 the cardiologist?

3 A. Typically, that's correct.

4 Q. What are the risks of giving TPA?

5 A. The main risk is bleeding, especially

6 intracranial bleeding. In this particular case,

7 there were no significant contraindications to

8 thrombolytic therapy or anticoagulation, for that

9 matter.

10 Q. Is it your testimony that Mr. Jacobs had

11 he been diagnosed with pulmonary embolism by

12 12:30 a.m. met published criteria for TPA?

13 A. No, that's not my testimony. My testimony

14 is that he would have been initially treated with

15 anticoagulation and the decision whether or not to

16 use TPA would have been based on a combination of

17 clinical and radiographic criteria.

18 Q. So you're not taking a position to a

19 reasonable degree of probability as to whether or

20 not those clinical and radiographical criteria

21 would have met the eligibility criteria for TPA?

22 MR. SUMMERS: I think he answered

95

1 that, but you can answer it again, Doctor.

2 A. My opinion is that we don't know because

3 they didn't do the studies to let us know whether

4 there was right heart strain or not. So it's hard

5 to answer the hypothetical question here.

6 Q. Well, I'm sure you know as an experienced

7 expert witness that we're entitled to explore your

8 opinions with hypotheticals. And I realize that

9 sometimes you can give an answer and sometimes the

10 answer is "I don't know". But in this case, as to

11 whether or not Mr. Jacobs likely would have met

12 the eligibility criteria for TPA and had been

13 given TPA had he been diagnosed with pulmonary

14 embolism by 12:30 a.m., are you going to take a

15 position at trial to a reasonable degree of

16 probability about that?

17 MR. SUMMERS: The "about that" part,

18 I am not sure is clear, but if you can answer,

19 Doctor, go ahead.

20 A. I'll answer you the best I can, and that

21 is a stat CT scan likely would have shown right

22 heart strain. At that point a stat echocardiogram

96

1 would have been performed, and if it showed right

2 heart strain with moderate RV dysfunction, then he

3 should have received TPA. I can't answer your

4 question beyond that because this patient was not

5 given the appropriate diagnostic studies before he

6 had his cardiac arrest.

7 Q. How long would it take to get the stat

8 echocardiogram?

9 A. Are you asking specifically at Saint Agnes

10 hospital?

11 Q. Yes. Under the same hypothetical, after

12 the stat CT scan that you believe would have been

13 accomplished by 12:30 a.m., I gather it's your

14 opinion that the next likely workup would have

15 been a stat electrocardiogram; is that right?

16 A. In terms of the decision to administer

17 TPA, I think a stat echocardiogram would have been

18 the next test. Keep in mind, Heparin should have

19 been started right away after the CT findings. In

20 terms of how long it would take to get an

21 echocardiogram, it just depends on how fast the

22 cardiologist or the echo tech can do the study.



25 (Pages 97 to 100)

97

1 But it should be done within an hour or two hours,

2 at the latest, because this is a lethal condition

3 that's treatable. You can prevent a patient from

4 dying. And if the hospital doesn't have the

5 capability, then the patient should be transferred

6 to somewhere that can do it quickly.

7 Q. Are echotechs at your hospital around the

8 clock?

9 A. They are not, but we have cardiology

10 fellows and sometimes the ER doctors can use

11 ultrasound to make a preliminary determination.

12 Q. So, under the hypothetical, you believe

13 that granted Heparin should have been started

14 after the CT scan, is that right, by 12:30 a.m.

15 Heparin should have been started under this

16 hypothetical?

17 A. Yes.

18 Q. In what dose?

19 A. Heparin is a weight based nomogram,

20 usually a bolus followed by a drip. I don't know

21 the specific dosing regimen.

22 Q. You're not going to come to trial and

98

1 offer an opinion as to specifically what doses of

2 IV Heparin that the patient should have gotten

3 under the hypothetical; is that fair?

4 MR. SUMMERS: I'll object. I think

5 he's saying he hasn't calculated it right there

6 but I guess he could do it if he wanted to.

7 BY MS. MADDEN:

8 Q. Okay. Well, whatever the protocol is,

9 that's what he would get, you're saying, I guess?

10 A. Yeah. It's a weight based dose that is

11 monitored by PTT times and the dose would have to

12 be adjusted depending on how the patient responds.

13 Q. Do you know what the gold posts are for

14 INR, PT, PTT ranges, or anything like that, in

15 terms of the Heparin protocol?

16 A. Well, it's not INR, it would only be PTT

17 in terms of our measurements. But I don't

18 remember off the top of my head what the PTT

19 measurements are because it's all protocolized at

20 the hospital.

21 Q. If this were your patient under this

22 hypothetical, would you consult any other

99

1 specialists or any specialist in terms of dosing

2 the IV Heparin?

3 A. Are we talking about this patient or a

4 hypothetical patient of mine?

5 Q. Let's make this patient a hypothetical

6 patient of yours. And tell me after the stat

7 CT scan, the stat echo, I guess, is ordered and in

8 the meantime IV Heparin is started that's weight

9 based according to a protocol. Before you ask for

10 that Heparin, would you be consulting with any

11 specialists about Heparin dosing or further workup

12 or treatment?

13 A. No.

14 Q. So, within a standard of care, you believe

15 the stat echocardiogram should have been

16 performed, at the latest, one to two hours after

17 the stat CT scan comes back?

18 A. If the CT scan showed right heart strain,

19 yes.

20 Q. And you may have answered this already,

21 Doctor, but you believe it would have shown right

22 heart strain or are you not taking a position on

100

1 that?

2 A. I think it likely would have shown some

3 right heart strain, but I can't tell you for sure

4 that it would have.

5 Q. Are you going to come to trial and state

6 hypothetically had they done a stat CT scan, they

7 would have seen right heart strain sufficient to

8 consider TPA?

9 A. Yes.

10 Q. You mentioned that in addition to starting

11 Heparin, the next step would have been a stat

12 echocardiogram that should have performed within

13 one to two hours after the CT scan comes back;

14 correct?

15 A. Again, if there was evidence of right

16 heart strain, yes, then a stat echocardiogram

17 would be the next step.

18 Q. Do you have an opinion to a reasonable

19 degree of medical probability under this

20 hypothetical as to what a stat echocardiogram done

21 within one to two hours of the CT scan would have

22 shown?



26 (Pages 101 to 104)

101

1 A. Yes. It would have shown right heart

2 strain with reduced right ventricular function.

3 Q. How would that have been quantified? Can

4 you be more specific, in other words?

5 A. I'm not a cardiologist in terms of all the

6 echocardiographic criteria, but typically they

7 would report it as normal RV function, mild,

8 moderate or severe dysfunction. But beyond that

9 I'm not sure. Usually they tell us whether the

10 right heart looks normal and is functioning

11 normally. They would also tell us the size of the

12 right heart and if it's dilated or not.

13 Q. Um-hum. Are you going to come to trial

14 and take the position under such a hypothetical as

15 to what type of right ventricular function or

16 dysfunction or size of the heart would have been

17 evident by echocardiography?

18 A. No. I'm not going to get into specifics

19 as to what the echo would have shown beyond there

20 being an abnormality of the right heart.

21 Q. I think you mentioned earlier that you

22 believe under this hypothetical TPA would have

102

1 been started if the stat echocardiogram showed

2 right heart strain with moderate dysfunction --

3 moderate right ventricular dysfunction; did I hear

4 you correctly?

5 A. Yes.

6 Q. Are you going to testify at trial to a

7 reasonable degree of medical probability that the

8 stat echocardiogram likely would have shown, at

9 least, moderate right ventricular dysfunction?

10 A. That's a hard question for me to answer.

11 I don't know what the echo would have shown

12 because it wasn't done, obviously. I do think it

13 would have shown some degree of right heart

14 dysfunction, whether it was mild, moderate or

15 severe, I don't know.

16 Q. So, under this hypothetical, had a stat

17 echocardiogram been done with the understanding

18 that you believe there would have been some degree

19 of right ventricular dysfunction, do you know to a

20 reasonable degree of medical probability whether

21 there would have been enough to mandate TPA or

22 would it have been a judgment call?

103

1 A. I'm not going to testify that it would

2 have mandated use of TPA, but it certainly would

3 have been a discussion and to a certain degree a

4 judgment call. Keep in mind that

5 echocardiographic findings can be dynamic, and you

6 can have moderate dysfunction which can improve.

7 The decision whether or not to give TPA is not

8 solely based on the echo, it's also based on how

9 the patient is doing clinically. It certainly

10 wouldn't be mandated based on what we know.

11 A. So, under this hypothetical, the stat

12 echocardiogram probably, in your opinion, would

13 have shown some degree of right ventricular

14 dysfunction but you're not going to come to trial

15 and say that the patient would have been given TPA

16 based on the stat echocardiogram and the rest of

17 the clinical findings; is that fair?

18 A. That's fair.

19 Q. I know I skipped over a time period in the

20 patient's course at Saint Agnes. Let me just keep

21 going. After the code, did you look at the

22 records that demonstrated that he developed

104

1 disseminated intravascular coagulation at the end

2 of his hospitalization?

3 A. Yes.

4 Q. Do you have an opinion as to why that

5 occurred?

6 A. Why did the DIC occur? I'm not sure. I

7 know he was transfused multiple units. Sometimes

8 patients who are transfused multiple units or are

9 hypotensive, in shock, can develop the DIC. But

10 beyond that I don't think it's known.

11 Q. Would you defer to a board certified

12 hematologist as to the cause of Mr. Jacobs' DIC?

13 A. Not necessarily, no. I think the role of

14 the hematologist in this case is probably

15 limited. I think this is a case of pulmonary

16 embolism, failure to diagnose it, and I just don't

17 see a high role for a hematologist in this case.

18 Q. My question was not what role you see for

19 a hematologist in this case. The question was in

20 terms of board certified physicians and

21 specialists examining this case and offering

22 opinions about this case, would you defer to a



27 (Pages 105 to 108)

105

1 board certified hematologist as to why Mr. Jacobs

2 developed DIC?

3 A. I wouldn't defer to them. I would listen

4 to what they have to say and form my own opinion.

5 Without further testing, I don't think anyone

6 knows why he developed DIC.

7 Q. Sitting here today, you don't know why he

8 developed his DIC; correct?

9 A. I don't have the exact cause. Like I said

10 earlier, there's a couple possibilities. He also

11 had an infection which can cause DIC. There's

12 numerous causes that could have caused a DIC.

13 Q. What are the other causes of DIC?

14 A. Sepsis, medications. Those are probably

15 the most common cases of DIC.

16 Q. Sepsis and medications?

17 A. Yes. Along with multiple transfusions.

18 Those are the common causes of DIC.

19 Q. You're not going to offer at opinion at

20 trial that something specifically was done

21 separate and apart from your opinions about

22 diagnosing and treating pulmonary embolism that

106

1 triggered the DIC in this patient; correct?

2 A. I'm aware that he received TPA. TPA can

3 certainly cause coagulation abnormalities. I

4 don't fault anyone in this case for the patient

5 getting -- for specifically getting DIC. The

6 concern I have is that they didn't diagnose the


8 Q. That's what I had understood, but I just

9 wanted to clarify.

10 I won't prolong this, but just generally,

11 Doctor, how often do you treat DIC in your own

12 patients, or in patient at the hospital?

13 A. DIC, in my experience, has been in

14 patients who are typically in the ICU or septic.

15 I would say a few patients per month.

16 Q. Do you consult with other specialists in

17 terms of determining how to treat patients with

18 DIC or do you manage that yourself?

19 A. Number one, in most cases there's no

20 specific treatment of DIC. The treatment of DIC,

21 in general, is the treatment of the underlying

22 condition. So, it would depend on the patient.

107

1 And typically these are patients who are septic,

2 on antibiotics, or vasopressors who may or may not

3 have consultants on board.

4 Q. Do you ever manage it yourself or do you

5 always consult someone, or sometimes you do or

6 sometimes you don't? I'm just trying to get a

7 sense of that.

8 A. Sometimes I do, sometimes I don't.

9 Q. You mentioned elevated troponins in this

10 case. Do those play a role in your opinions about

11 the recognition and treatment of pulmonary

12 embolism?

13 A. Yes.

14 Q. How so?

15 A. Troponin is a very sensitive and specific

16 marker of myocardial injury and in this case it

17 should have pointed the caregivers in the

18 direction of a cardiopulmonary event. You have

19 two abnormal troponins, and along with the other

20 clinical criteria, should have triggered the

21 investigation towards pulmonary embolism.

22 Q. Had Kareem Jacobs suffered myocardial

108

1 injury to explain his elevated troponins?

2 A. Yes. By definition if you have positive

3 troponins, you have leakage of enzymes from

4 myocardial tissue.

5 Q. A positive troponin is not by itself

6 diagnostic of a PE; correct?

7 A. It's not diagnostic of a PE, but it

8 certainly is suggestive. You have a 19-year-old

9 patient with no known coronary disease, no known

10 high blood pressure, does not have high

11 cholesterol, does not smoke. With this type of

12 presentation positive cardiac enzymes are

13 certainly concerning for pulmonary embolism.

14 Q. What else might positive troponins be

15 concerning for in a patient of this age?

16 A. You can sometimes see it in myo- or

17 pericarditis. You can occasionally see it if

18 there's blunt force trauma to the myocardium.

19 But, again, I would be most concerned about

20 pulmonary embolism, especially when you combine it

21 with the hypoxia, tachycardia, the recent

22 immobilization, and the abnormal chest X-ray. You



28 (Pages 109 to 112)

109

1 had many signals here that this patient was having

2 a pulmonary embolism.

3 Q. Thank you. What was abnormal about the

4 chest X-ray?

5 A. The report showed an enlarged cardiac

6 silhouette.

7 Q. What are the possible explanations for

8 that?

9 A. There are many possible explanations. It

10 could be infection, fluid around the heart, fluid

11 in the lungs. But when you combine it with

12 tachycardia, hypoxia, recent immobilization, an

13 abnormal EKG, and abnormal cardiac enzymes, this

14 is a patient that needed a workup for a pulmonary

15 embolism.

16 Q. Is the workup that you believe should have

17 occurred after the 11:30 phone call the same

18 workup that you believe should have occurred

19 earlier in the emergency department?

20 A. Yes. A stat CT scan of the chest, PE

21 protocol, was the appropriate workup. There are

22 other options that could have been pursued such as

110

1 lower extremity venous dopplers or D-dimer blood

2 test. If either of those were positive, then that

3 would have been diagnostic of thromboembolic

4 disease as well.

5 Q. Do you have an opinion as to whether those

6 studies, had they been done, likely would have

7 been positive?

8 A. Yes. They likely would have been

9 positive.

10 Q. Do you believe this patient had a

11 diagnosable DVT by doppler in the emergency room

12 at Saint Agnes?

13 A. Likely, yes.

14 Q. What's the basis of that opinion?

15 A. The vast majority of pulmonary emboli come

16 from lower extremity DVTs. And we know that this

17 patient had a recent ankle injury causing

18 immobilization, reduced activity. Unless the

19 entire clot was gone -- I don't believe that was

20 the case -- then the doppler likely would have

21 shown a clot in the leg.

22 Q. You agree that it's rare to see a

111

1 pulmonary embolism in an otherwise previously

2 healthy 19-year-old male; correct?

3 A. I would characterize it as uncommon, but

4 in a patient who presents like this, it would be

5 at the top of my differential diagnosis.

6 Q. That's a different question. In terms of

7 how often you see it in a 19-year-old patient it's

8 rare, isn't it?

9 A. Certainly if you take all 19-year-olds it

10 is rare. But if you take a 19-year-old who has a

11 leg injury and then has these types of vital

12 signs, it would be at the top of my differential

13 diagnosis.

14 Q. How many times do you see it in teenagers

15 who sprain their ankle?

16 A. I've seen many patients who who strained

17 their ankles -- but this is not just an ankle

18 sprain. This was fairly severe enough where they

19 had to immobilize the patient.

20 Q. What do you mean they had to immobilize

21 the patient? I mean, was there a diagnosed

22 fracture?

112

1 A. There was not a diagnosed fracture,

2 although as we know, the X-ray initially can miss

3 fracture. He was given a cast and treated as if

4 he had a fracture.

5 Q. And he was referred to an orthopedist?

6 A. Yes.

7 Q. And he do not go and see the orthopedist?


9 Q. In terms of your younger patients, we'll

10 say under 21 -- you see teenagers in your

11 practice, I assume; correct?

12 A. I usually start seeing patients at the age

13 of 18 and older.

14 Q. Can you remember ever in your practice

15 seeing a patient 18, 19, 20 years old with a

16 history of a sprain or a break of the ankle or

17 foot who ended up dying of a pulmonary embolism?

18 A. Yes.

19 Q. How many times did that happen to you?

20 A. Not many. Fortunately, it's only been one

21 or two times. But I see a lot of patients from

22 the orthopedic service, because we are consulted



29 (Pages 113 to 116)

113

1 on these patients, and even a younger patient who

2 has a lower extremity injury can have a pulmonary

3 embolism.

4 Q. Well, you said lower extremity, I'm

5 limiting it to the foot or ankle. That's

6 different; right? There's a different risk

7 profile for someone who's got a knee or a hip

8 injury as opposed to a foot or ankle injury;

9 correct?

10 A. It's different, but they're all at high

11 risk. Anyone who is immobilized or not as active

12 would be at higher risk.

13 Q. Is it your testimony that the risk for

14 developing DVT or PE is the same, all other things

15 being equal, for patients who have foot/ankle

16 injury versus patients who have hip or knee

17 injuries?

18 A. No.

19 Q. The patient with the foot or ankle injury

20 has a lower risk, all other things being equal,

21 than patients with hip or knee injury; correct?

22 A. Counsel, it's a very broad question. A

114

1 mild hip injury versus a severe ankle or foot

2 injury, I would believe that the severe foot or

3 ankle injury would be higher risk for DVT. If

4 this degree of severity of the injuries are all

5 the same, then I would say the hip and knee

6 patients are at higher risk. But we can't forget

7 that these patients with ankle or foot injuries

8 can still develop a DVT.

9 Q. Do you know what the incidence is of young

10 otherwise healthy patients who sprain or fracture

11 a foot or ankle go on to develop pulmonary

12 embolism?

13 A. The overall incidence is very low,

14 fortunately.

15 Q. Probably less than 2 percent?

16 A. I think if you're including every patient

17 that sprains their ankle of any degree, then,

18 yeah, I would probably say less than 5 percent,

19 but I don't know the exact number.

20 Q. Do you have any role at your hospital in

21 terms of maintaining equipment?

22 A. No.

115

1 Q. Are you going to offer any opinions at

2 trial about the resuscitation after the first

3 code?

4 A. Yes.

5 Q. Do you agree that this patient suffered a

6 PEA arrest close to 5:30 in the morning on the

7 21st; correct?

8 A. Yes.

9 Q. That's pulseless electrical activity;

10 correct?

11 A. Yes.

12 Q. You understand that statistically a

13 patient in PEA arrest is unlikely to survive;

14 correct?

15 A. They are less likely to survive than other

16 forms of cardiac arrest. That's correct.

17 Q. And their chances of surviving a PEA

18 arrest, and this is for hospital in patients like

19 Mr. Jacobs, are less than 50 percent?

20 A. That's correct. And that's largely due to

21 patients dying in the hospital from pulmonary

22 embolism.

116

1 Q. At the time Mr. Jacobs suffered his PEA

2 arrest at close to 5:30 in the morning on the

3 21st, he was statistically unlikely to survive the

4 discharge; correct?

5 MR. SUMMERS: Objection. You can

6 answer.

7 A. I believe your prior question referred to

8 all patients. We're talking now about a patient

9 who is in the emergency department, I would expect

10 that patient to be resuscitated and survive to

11 discharge.

12 Q. What literature are you relying on that

13 for that position?

14 MR. SUMMERS: I object. I think he's

15 answered it three times now, and he's not relying

16 on any literature. But if you have some

17 literature now, Doctor, go ahead and tell her.

18 A. I'm not relying on any literature. I'm

19 relying my clinical experience that a 19-year-old

20 who has a cardiac arrest in the emergency

21 department typically is resuscitated

22 successfully.



30 (Pages 117 to 120)

117

1 Q. Do you have any criticisms of any of the

2 individuals involved in the resuscitation effort?

3 A. Well, after I reviewed the deposition

4 transcript of Dr. Falck, I learned that there was

5 a 20-minute delay from the cardiac arrest until

6 the intubation, which in my opinion is a deviation

7 of standard of care. In terms of who was

8 responsible for that, I think there are likely a

9 number of people. There apparently was two

10 separate equipment malfunctions and the patient

11 was not intubated until anesthesia arrived. But

12 20 minutes is not an acceptable time frame for a

13 patient in the ER to be intubated.

14 Q. In terms of who specifically was

15 responsible for what you believe was a delay, are

16 you identifying anyone in particular?

17 A. I think the ER doctor would be the primary

18 person that is responsible for intubating this

19 patient or calling in anesthesia sooner to

20 intubate the patient.

21 Q. Would you expect someone who tried to --

22 well, there was no note about any effort Dr. Falck

118

1 made to intubate the patient; correct?

2 A. Correct.

3 Q. Do you know what specific types of

4 equipment he was talking about when you said he

5 couldn't get it to work correctly?

6 A. I believe he was referring to the screen

7 and the light on the equipment that he was using

8 to visualize the vocal cords.

9 Q. Do you intubate patients, Doctor?

10 A. No.

11 Q. Do you have privileges to intubate?

12 A. No.

13 Q. Do you have any understanding of how a

14 flickering light -- how readily a flickering light

15 on a laryngeal scope or a slide scope is fixed

16 during a code situation?

17 MS. MALONE: I object to the form.

18 MR. SUMMERS: I object to the form as

19 well. This is Tom Summers.

20 A. Counsel, I'm not sure what you're asking

21 me. My position is this, a patient who suffers a

22 cardiac arrest in the emergency department needs

119

1 to be intubated as soon as possible, and 20

2 minutes is too long. If the ER doctor can't do it

3 within a few minutes, then the anesthesiologist

4 needs to be contacted. And the fact that there's

5 no documented note by the ER doc is very

6 concerning to me, that there wasn't a description

7 as to what happened in this case.

8 Q. You don't have any criticism of the

9 anesthesiologist's response in intubating the

10 patient; correct?


12 Q. Understanding that you don't intubate

13 patients yourself, do you understand that

14 sometimes patients are not successfully intubated

15 because they have a difficult airway?

16 A. I do understand that. I have intubated

17 patients in the past. I did it during my

18 training. I haven't done it in over ten years.

19 Not every patient has an easy airway to intubate,

20 but you cannot allow a patient to be hypoxic for a

21 period of time that's going to cause permanent

22 brain injury, especially if there is a more

120

1 qualified physician who can readily intubate the

2 patient.

3 Q. Based on the records, did the

4 anesthesiologist readily intubate the patient?

5 A. It appears so, yes.

6 Q. The extent of any injury that a patient

7 would sustain from -- I'll use your word -- a

8 delay in intubation during the code depends on

9 whether or not the patient can be adequately

10 ventilated and having good chest compressions

11 during CPR; correct?

12 A. That's generally true. That's correct.

13 Q. Are you going to come to trial and point

14 to any particular point in time during the code

15 when you believe the patient was no longer

16 adequately ventilated and/or not receiving good

17 enough chest compressions that he sustained

18 irreversible injury?

19 A. From the deposition testimony of

20 Dr. Falck, the patient's pulse ox readings were

21 around the 80s. That is significantly decreased

22 and would cause harm. It would cause cerebral



31 (Pages 121 to 124)

121

1 anoxia.

2 Q. But my question is, are you going to point

3 to some specific point in time during the code and

4 say in-between the time that the code was called

5 and the patient was intubated, are you going to

6 come to trial and point to a specific point in

7 time and say by this point Mr. Jacobs was no

8 longer salvageable or had sustained irreversible

9 brain injury?

10 MR. SUMMERS: Shannon, you just mean

11 during this so-called 20-minute time period -- go

12 ahead, Doctor, if you have an opinion, go ahead.

13 A. I think the point of significant harm to

14 the patient occurred when he suffered this PEA

15 arrest. Any time prior to that, you know, if the

16 CT scan been done and the blood thinners had been

17 used, he would have recovered. Once he suffers

18 this PEA arrest and they can't intubate him for

19 20 minutes, I think any time during that 20-minute

20 period he is suffering cerebral hypoxia and will

21 no longer return to his baseline.

22 Q. So you're not going to come to trial and

122

1 just say -- understanding your opinions about

2 earlier treatment of the pulmonary embolism and

3 what harm you think that caused and the PEA arrest

4 itself would have caused some harm, I presume --

5 but aside from that, are you going to come to

6 trial and say X minutes after the code was called

7 or X minutes before the patient was intubated, I

8 think he was either no longer salvageable or had

9 suffered additional irreversible injury apart from

10 what you believe had already occurred?

11 MR. SUMMERS: I object. I think that

12 question would be the reverse of that, when in

13 time should it have happened, but, Doctor, you can

14 answer the question either way.

15 A. There's a spectrum of damage that was done

16 to this patient and with each passing minute that

17 his brain was deprived of enough oxygen, he

18 suffered additional brain injury. It's difficult

19 to determine at what point he would be, to use

20 your term, salvageable, but I don't believe that

21 he would have returned to his baseline neurologic

22 function, I would say, after a few minutes of

123

1 suffering cerebral hypoxia. And that's based on

2 general knowledge of brain injury. That certainly

3 after five minutes of cerebral hypoxia, patients

4 are less likely than not to return to their

5 baseline.

6 Q. Did Mr. Jacobs suffer irreversible brain

7 injury by the time of his PEA arrest when the code

8 was called?

9 A. It depends on how long he had cerebral

10 hypoxia by the time the code was called. It's

11 hard to know for sure based on the documentation.

12 Q. So you're not going to offer an opinion on

13 that at trial; correct?

14 A. No. My opinion is up until the time that

15 he coded he was fully salvageable that he could

16 have been saved, he would have been at his

17 baseline. Any time after he suffers the PEA, he's

18 at risk for not returning to his baseline.

19 Q. And he's at risk for not surviving;

20 correct?

21 A. That's correct also.

22 Q. Is it your opinion to a reasonable degree

124

1 of medical probability that if the patient had

2 been given just Heparin within the time that you

3 believe it should have been started under the

4 standard of care that he likely would have

5 survived?

6 A. Yes.

7 Q. When do you believe Heparin was required

8 by the standard of care to have been started in

9 this case? Under the one scenario we talked about

10 it was 12:30 a.m., so let me just stick with

11 that. If Mr. Jacobs had been given IV Heparin

12 under usual dosing protocols starting at 12:30

13 a.m., and let's assume no TPA was given, do you

14 believe the patient -- do you have an opinion as

15 to the patient's likelihood of survival?

16 A. Yes. I think it's highly likely the

17 patient would have survived. Keeping in mind that

18 I would not start the time clock at 12:30, I would

19 start it much earlier. This patient presented the

20 evening before and required a workup as soon as he

21 arrived in the emergency department. I believe

22 the standard of care required this workup to have



32 (Pages 125 to 128)

125

1 occurred 8:00 or 9:00 p.m. the night before. But

2 even if it would have been started as late as

3 12:30 in the morning, it's very likely he would

4 have survived had he been treated appropriately.

5 Q. And that could have been with Heparin

6 alone, in your opinion?

7 A. Yes.

8 Q. And I'm sticking with that 12:30

9 hypothetical, understanding you have an opinion

10 that it should have been started earlier, can you

11 just tell me briefly, mechanically, how you think

12 Heparin had it been started hypothetically at

13 12:30 a.m. would have prevented the PEA arrest at

14 approximately 5:30 in the morning?

15 A. Sure. Heparin is an anticoagulant, it

16 thins the blood, it's not a thrombolytic. So it

17 doesn't break up existing clot, but it thins the

18 blood and makes it highly unlikely that a new clot

19 will form. In my clinical experience, it's

20 unlikely for patients to suffer a fatal or massive

21 pulmonary embolism on anticoagulation. It's very

22 unlikely. And the vast majority of patients who

126

1 are treated with Heparin will do well with their


3 Q. Have you kept track of your own patients

4 in terms of how they do with pulmonary embolism

5 and Heparin, do you have some data in terms of

6 your experience, or is this your overall sense of

7 what you've seen?

8 A. I don't have specific records on all my

9 patients with pulmonary embolism. This would be

10 based on my clinical experience that it's highly

11 unusual for patients to develop a lethal or

12 massive thromboembolic event on Heparin.

13 Q. Do you know what the incidence is of

14 patients with pulmonary embolism who go on to

15 develop a massive thromboembolic event even on

16 Heparin?

17 A. I don't know if anyone knows that

18 incidence. It would depend on the patient, it

19 would depend on how well the Heparin is

20 administered. Assuming that we are in a

21 therapeutic range in a patient who does not have

22 an underlying hypercoagulable state, it would be a

127

1 rare occurrence for that to happen.

2 Q. I'm just looking over my notes, Doctor,

3 I'm sure I'm going to have more questions for you

4 but I just don't want to keep pausing and

5 prolonging your pain unnecessarily. With

6 Mr. Summers' and your permission, I may just pass

7 the baton to the other attorneys so they can get

8 their questions in while they're still awake and

9 then I can ask any follow-ups questions I may have

10 at the end if that's okay with you.

11 A. Yes.

12 Q. Then, I'll do that now.

13 (Recess.)

14 EXAMINATION

15 BY MS. MALONE:

16 Q. Doctor, let me just start out by asking

17 you to identify all of the individuals that you

18 believe violated standards of care in the care

19 management and treatment of Mr. Jacobs when he was

20 in the emergency department at Saint Agnes on

21 August 20th through the 21st.

22 A. That would be Dr. Meer, Dr. Falck,

128

1 Physician Assistant Alton, and Dr. Awan would be

2 the individuals who violated the standard of care.

3 Q. Doctor, would you please outline for me

4 the breaches in the standard of care that you

5 believe were committed by Dr. Meer.

6 A. Dr. Meer failed to include pulmonary

7 embolism on his differential diagnosis and failed

8 to perform diagnostic studies that would have been

9 diagnostic of a pulmonary embolism.

10 Q. What's the basis for your opinion that he

11 failed to include PE on his differential?

12 A. His deposition testimony, I reviewed the

13 transcript where he said that DVT and pulmonary

14 embolism did not appear on his differential.

15 Q. And I take it it's your opinion that he

16 should have included PE on his differential?

17 A. Absolutely. Yes.

18 Q. What's the basis of that?

19 A. We have a patient at risk for

20 thromboembolic disease, he has a lower extremity

21 injury. He did not leave the house from time of

22 his prior ER visit until this episode.



33 (Pages 129 to 132)

129

1 Immobilization is a risk factor for DVT. He

2 reports chest fluttering. His vital signs are

3 abnormal including an elevated heart rate. His

4 oxygen level was low. His blood pressure was

5 low. He has abnormal cardiac enzymes and an

6 enlarged cardiac silhouette on the chest X-ray.

7 Pulmonary embolism should have been at the

8 top of the list in a patient who presents like

9 this.

10 Q. Anything else?

11 A. Anything else in terms of his deviation of

12 standard of care?

13 Q. No. Anything else to support your opinion

14 that Dr. Meer should have included PE on his

15 differential.

16 A. I think the fact that this patient had

17 this unprovoked apparent seizure or seizure-like

18 activity, we know that hypoxia is on the list of

19 causes of seizure. In an otherwise healthy

20 patient, that should have triggered the thought

21 that this patient had a pulmonary embolism.

22 Q. Anything else?

130

1 A. I believe that I have covered all my

2 opinions as to how he deviated in the standard of

3 care. He did not document much in his note, but

4 my opinions are mostly based on his lack of

5 ordering the appropriate tests and providing the

6 appropriate treatment.

7 A. Your second criticism was that he failed

8 to perform diagnostic studies, or I should say

9 diagnostic studies which would have been

10 diagnostic of PE; correct?

11 A. Yes.

12 Q. In terms of increased heart rate, what was

13 the increased heart rate that you believe should

14 have caused him to consider, in conjunction with

15 other things, a PE?

16 A. There's no one heart rate that would have

17 by itself triggered the need to evaluate for PE.

18 It's a constellation of signs and symptoms that

19 makes PE the top of the differential diagnosis.

20 If we look back at this patient's heart rate when

21 he was in the ER a couple days earlier with eight

22 out of ten pain in his ankle, his rate was 68

131

1 beats per minute. His heart rate during the

2 second ER visit was 100, and that is abnormal for

3 this patient. It's abnormal. And it's one of the

4 common presenting signs of pulmonary embolism.

5 Q. Do you consider a heart rate of 100 to be

6 tachycardia pursuant to any particular definition

7 in the medical literature?

8 A. It depends on where you're looking. Some

9 places will say a heart rate of 60 to 100 is

10 considered normal. But in a 19-year-old otherwise

11 healthy patient in whom we have data that their

12 heart rate was 68 a few days earlier in the

13 setting of eight out of ten ankle pain, this

14 patient would be considered tachycardic.

15 Q. You, as I understand it, have never worked

16 as an emergency medicine physician; is that right?

17 A. Correct.

18 Q. So, would it be fair to say that you don't

19 know whether or not the standard of care required

20 a provider to look back at prior vital signs of a

21 patient who had been seen a couple days earlier;

22 would that be fair?

132

1 MR. SUMMERS: I object. I'm not sure

2 I understand how those two parts of that question

3 coincide or correlate, but you can answer, Doctor,

4 if you can.

5 A. Counsel, this is my position. The vital

6 signs are a heart rate of 100, pulse ox of

7 91 percent. In terms of whether or not the heart

8 rate of 100 is tachycardic, I am telling you that

9 in this case it is. A 19-year-old should not have

10 a heart rate of 100. And certainly if the patient

11 presented to the same ER a couple days earlier,

12 those records should be available for review. But

13 even without them, the constellation of signs and

14 symptoms would be consistent with pulmonary

15 embolism.

16 Q. So what you're saying is, even if someone

17 had known or hadn't known of the 68 a couple days

18 earlier, it's your opinion that the heart rate of

19 100 should have been recognized as abnormal in a

20 patient like Mr. Jacobs as he presented?

21 A. That's correct. And, again, I am

22 testifying that there's a constellation of



34 (Pages 133 to 136)

133

1 abnormalities here when taken together make

2 pulmonary embolism the top diagnosis to rule out.

3 Again, this is a patient who presented with

4 fluttering in the chest, along with a heart rate

5 of 100. So not only do we have an objective

6 measurement that his heart rate was fast, it's

7 also subjectively abnormal for this patient. And

8 along with the other vital signs and labs and

9 X-ray would require workup for PE.

10 Q. In terms of the diagnostic studies that

11 you say he should have performed, or I guess

12 ordered to be performed, could you tell me what

13 those are?

14 A. There are several that could have been

15 performed. The most commonly performed test is a

16 stat CT scan of the chest with contrast, and that

17 would have diagnosed pulmonary embolism. Other

18 options would include lower extremity venous

19 dopplers, a blood test called a D-dimer. And

20 there are other tests as well that could have been

21 done, including a VQ scan. Although most

22 hospitals are generally unable to get a VQ scan

134

1 done urgently in the evening.

2 Q. Just in terms of the diagnostic studies

3 that you just outlined, given the setting of this

4 case, which ones do you believe more likely than

5 not should have been obtained and ordered by Dr.

6 Meer in order to meet standard of care?

7 A. Certainly the CT scan of the chest should

8 have been ordered to meet the standard of care.

9 The lower extremity doppler and the D-dimer were

10 other options, and I believe they would have been

11 positive and the treatment would have been the

12 same, which is anticoagulation. So, the CT scan

13 would have been my first choice.

14 Q. So if he had ordered the stat CT scan of

15 the chest and not the other things, that would

16 have been complied with standard of care in your

17 view?

18 A. Yes. If an institution has experience in

19 performing and interpreting a CT scan for

20 pulmonary embolism, I believe that the sensitivity

21 of the test is high enough that no other tests

22 would have needed to be performed if it would not

135

1 have shown pulmonary embolism.

2 Q. If a CT scan of the chest had been done,

3 at what point in time do you think that should

4 have occurred given the times that Dr. Meer became

5 involved in the care?

6 A. I believe the CT scan should have

7 performed within one hour of the patient

8 presenting to the emergency department. I

9 understand that sometimes it's very busy in the

10 ER, but this is a patient coming in with abnormal

11 vital signs and a life-threatening condition and I

12 think a CT scan needs to be done within an hour.

13 Q. Then, in terms of getting an

14 interpretation of the CT scan, how long do you

15 believe that would have taken in this setting?

16 A. Depending on the capability of the

17 radiologist, typically you should be able to get a

18 read within 15 minutes. I would say the upper

19 limit of normal for standard of care would be

20 another hour.

21 Q. We know that Dr. Meer saw the patient

22 somewhere around 8:29, 8:30; correct?

136

1 A. Yes.

2 Q. So that would mean that by about 10:30 you

3 believe that an interpretation of a CT scan of the

4 chest would have been available?

5 A. Yes.

6 Q. Now, in terms of the imaging studies; that

7 is, the CT scan of the chest, are you going to be

8 giving an opinion as to the clot burden that the

9 CT scan would have demonstrated in the vessels of

10 the of lungs?


12 the form and foundation of that question. I think

13 he's answered it partially in terms of what it

14 would have shown, but, Doctor, if you have a more

15 specific opinion, you certainly can give it.

16 A. I'm not going to testify about a specific

17 clot burden. The diagnosis of pulmonary embolism

18 and the treatment will be the treatment of -- I'm

19 sorry. The treatment of the pulmonary embolism

20 would have occurred regardless of the clot burden,

21 even a small pulmonary embolism that was

22 visualized would have led to the appropriate



35 (Pages 137 to 140)

137

1 therapy of IV Heparin.

2 Q. Do you know by 10:30 at night on August 20

3 what portions of the lungs had clots in them and

4 the particular areas of the lungs where the clot

5 or clots were located?

6 A. No, I don't because, of course, the

7 CT scan wasn't done, so we have no way of knowing.

8 Q. But I think you said earlier that you

9 thought that this would have been a massive

10 pulmonary embolism that would have been found on

11 an imaging study had one been done before he

12 arrested the next morning?

13 A. Yes. I do believe that a CT scan would

14 have been diagnostic, but I can't answer you

15 specifically in terms of where in the pulmonary

16 trunk or the vasculature the clot would have been.

17 Q. Was it likely not a saddle embolism at

18 that point, or or was it?

19 A. I don't believe he had a saddle embolism

20 at that point. The saddle embolism occurred later

21 on which caused his PEA arrest.

22 Q. You don't have any disagreement with what

138

1 the subsequent imaging study showed as to where

2 the clot or clots were located?

3 A. No. I did not review the CT scan myself.

4 I'm relying on the report in the medical records.

5 Q. Do you typically read CT scans of the

6 chest yourself?

7 A. For pulmonary embolism, I usually rely on

8 the radiologist.

9 Q. Assuming that at 10:30 the results of the

10 CT scan are known, outline for me in order what

11 you think should have been done for this patient

12 at that time.

13 A. The patient should have been treated with

14 IV Heparin, a weight based Heparin nomogram should

15 have been started, with frequent monitoring of his

16 PTT labs. A stat echocardiogram should have been

17 ordered to evaluate the right side of his heart.

18 And, of course, the patient should no longer have

19 been admitted to a regular floor or an

20 intermediate unit floor. This patient needed to

21 go to an ICU bed. So depending on the capability

22 of Saint Agnes, that would determine where the

139

1 patient would go next.

2 Q. Now, you gave testimony earlier as to a

3 stat echo had one been done after the phone call

4 to Dr. Awan when the patient was admitted;

5 correct?

6 A. I'm sorry, I don't understand the

7 question. Could you repeat it, please.

8 MR. KRUEGER: I object. He was

9 admitted to the ED before he was admitted to the

10 IMC, so it's not clear what you're asking him

11 about.

12 BY MS. MADDEN:

13 Q. Doctor, earlier you had given some

14 testimony when being asked questions by Counsel as

15 to what you thought an echocardiogram would have

16 shown had it been done; am I right about that?

17 A. Yes.

18 Q. My question for you is, is your testimony

19 that you've given earlier regarding

20 echocardiograms and what they may or may not have

21 shown the same if the echocardiogram had been done

22 earlier?

140


2 the form and foundation. I'm not sure I

3 understand that.

4 MS. MADDEN: I'm just trying to save

5 a little time. He gave a lot of testimony about

6 what he could and couldn't say about what

7 echocardiography would have shown, or an

8 echocardiogram. I'm trying to find out whether

9 his testimony would be any different if we backed

10 the timeline up a couple of hours.

11 MR. SUMMERS: I understand. Doctor,

12 if you can answer that, go ahead.

13 A. I'm not exactly sure what the

14 echocardiogram would have shown at each hour of

15 the patient's stay in the ER. Based on the

16 hemodynamic changes that he manifested when he

17 presented, I do believe that the echocardiogram

18 would have been abnormal, but I can't give you

19 detail in terms of how abnormal it would have

20 been.

21 Q. In terms of getting an echocardiogram

22 following a CT scan, tell me how long you think



36 (Pages 141 to 144)

141

1 that would have taken if it's any different than

2 what you said earlier? Do you see what I'm

3 saying?

4 A. The time frame should be the same as I

5 said earlier, a stat echocardiogram should be able

6 to be obtained in a patient like this that needs

7 one. Keep in mind that the treatment of pulmonary

8 embolism is going to be started well before the

9 echo is performed and interpreted. This is merely

10 -- the echocardiogram helps determine whether

11 thrombolytic therapy should also be given.

12 Q. Right. So, in this particular case, when

13 do you believe that IV Heparin should have been

14 started?

15 A. It should have been started as soon as the

16 CT scan was interpreted as showing pulmonary

17 embolism. I think we said earlier, at the latest,

18 10:00 or 10:30 at night.

19 Q. Have we covered the opinions that you have

20 regard to Dr. Meer and your opinions with regard

21 to what the standard of care should have required

22 him to do while he was taking care of the patient

142

1 in the emergency department?

2 A. My only other opinions would include his

3 information or communication with the other

4 physicians and whether or not he properly relayed

5 the situation, and I can't tell for sure whether

6 he did or not. In other words, when he called the

7 cardiologist and when he called Dr. Awan, I'm not

8 sure what information he relayed. If he did not

9 relay the information that he had a young patient

10 with a recent ankle injury who was hypoxic,

11 tachycardic, then that would be a deviation of

12 standard of care.

13 Q. Let me back you up just a second because

14 you mentioned a couple of providers there. Tell

15 me, in your opinion, with regard to his

16 communication the individuals you are speaking of

17 that he communicated with, according to the

18 records.

19 A. There was -- the initial communication, I

20 believe it was Dr. Dua, the cardiologist,

21 regarding the abnormal EKG. And then there was

22 the communication with the cardiologist regarding

143

1 the positive cardiac enzymes. And then there was

2 a communication with Dr. Awan, who was the

3 internist admitting the patient.

4 Q. Let me just ask you to accept that

5 Dr. Meer had no communication with Dr. Awan, would

6 that in any way affect your opinion that he has

7 deviated from the standard of care just in terms

8 of communicating with him?

9 A. Yes. If it was Dr. Falck, then, who

10 communicated with Dr. Awan, then that would change

11 my opinion regarding Dr. Meer's performance.

12 Q. We can take that off the list if in fact

13 he wasn't the one that communicated with Dr. Awan;

14 correct?

15 A. Yes.

16 Q. Now, let's go back to Dr. Dua and you

17 understand that he was the interventional

18 cardiologist on call; is that right?

19 A. Yes.

20 Q. Did you read Dr. Meer's testimony as to

21 what he in fact communicated to Dr. Dua?

22 A. Yes.

144

1 Q. What did he say?

2 MS. MADDEN: I object. The testimony

3 speaks for itself.

4 MR. SUMMERS: I object, too. I think

5 that's an unfair question. We have a depo, so I

6 guess he could just go to it and say what it is.

7 MS. MALONE: Let me ask it this way,

8 it might shorten things up.

9 BY MS. MALONE:

10 Q. Doctor, do you have an opinion as to what

11 Dr. Meer should have communicated to Dr. Dua when

12 he placed the call, first verbal communication, I

13 guess?

14 A. Yes, I do have an opinion.

15 Q. Go ahead.

16 A. An interventional cardiologist is a

17 physician. It's a physician who trained first in

18 internal medicine and then went on to become a

19 cardiologist and then has specialized training in

20 interventional cardiology, but they still have a

21 standard of care to care for a patient. And

22 Dr. Meer's responsibility was to communicate the



37 (Pages 145 to 148)

145

1 pertinent information in the case. I understand

2 from the deposition testimony that he primarily

3 called him because of the abnormal EKG. But when

4 we're talking about an abnormal EKG in a

5 19-year-old who doesn't smoke, who doesn't have

6 high blood pressure, who doesn't have high

7 cholesterol, you need to put this into a clinical

8 context. And if he did not communicate to the

9 cardiologist about all of the signs and symptoms

10 of pulmonary embolism, then that cardiologist

11 would have no way of advising that this patient

12 needed to be tested for a pulmonary embolism.

13 Q. So my question to you is, what does the

14 standard of care require him to communicate to

15 Dr. Dua?

16 A. In terms of pursuing the appropriate

17 treatment for a patient, physicians have a

18 responsibility to communicate all of the pertinent

19 information, which starts with the patient history

20 and the vital signs, and he certainly had a

21 responsibility to communicate that the patient's

22 pulse ox was 91 percent. He certainly had a

146

1 responsibility to communicate that the patient's

2 heart rate was 100, that he was complaining of

3 chest fluttering.

4 If he actually only communicated that he

5 has an abnormal EKG, in the absence of any other

6 clinical information, that would make it very

7 difficult for Dr. Dua to provide appropriate

8 consultation.

9 Q. Have you completed your answer?

10 A. Yes.

11 Q. As we pointed out earlier, what actually

12 occurred during the conversation is known by the

13 two communicators, Dr. Dua and Dr. Meer?

14 MR. SUMMERS: Objection. Is that a

15 question? I'm not sure whether you're telling him

16 that or asking him that.

17 MS. MALONE: I'm asking him that the

18 communication that occurred between Dr. Dua and

19 Dr. Meer is a communication that's known to those

20 two providers and not to us. We don't know what

21 was actually said in the conversation; is that

22 right.

147

1 MR. SUMMERS: Other than what we read

2 in testimony, but, Doc, you can answer it.

3 A. Of course, we don't know exactly what was

4 spoken. It's not well documented in the records

5 and it's somewhat unclear even from the deposition

6 testimony.

7 Q. Let's move on to the second cardiologist

8 who I think is Dr. Winekar. Doctor, what do you

9 believe that Dr. Meer was required to communicate

10 to doctor Dr. Winekar in addition to, I presume,

11 EKGs?

12 A. Everything that I previously answered for

13 Dr. Dua he was responsible to communicate to

14 Dr. Winekar; the entire clinical picture,

15 including the positive enzymes, the abnormal EKG,

16 abnormal chest X-ray, abnormal vital signs, and

17 the subjective report of fluttering in the chest.

18 Q. When you say everything you previously

19 said, you're incorporating your testimony as to

20 Dr. Dua and you're adding the enzymes to that?

21 A. Yes. Dr. Meer has now called two

22 different cardiologists, he's obviously showing

148

1 some level of concern about this patient's cardiac

2 status. And that was appropriate because this

3 patient was having a cardiac event, which

4 specifically was right heart dysfunction in the

5 setting of a pulmonary embolism.

6 Q. So what I was trying to say, his call to

7 these two consulting cardiologists was

8 appropriate, would you agree with that?

9 A. It's hard for me to answer that because we

10 don't know what the nature of the calls were, as

11 we discussed. I would say this, if I have a

12 19-year-old patient who doesn't smoke, doesn't

13 have diabetes, doesn't have high blood pressure,

14 doesn't have high cholesterol and the EKG findings

15 that we previously discussed, I am unlikely to be

16 calling an interventional cardiologist solely with

17 the question of whether or not a patient needs a

18 heart catheterization. The ER doctor's

19 responsibility is to evaluate the patient

20 globally. So, calling the cardiologist

21 specifically to ask about a heart cath would be a

22 deviation of standard of care given all of the



38 (Pages 149 to 152)

149

1 other signs and symptoms.

2 Q. Were there concerns about ST elevations in

3 certain of the leads that would have made it

4 appropriate for an emergency medicine physician --

5 understanding it's a 19-year-old -- to at least

6 call the interventionalist on call to see if that

7 individual thought that there was any need for

8 cardiac catheterization?

9 A. I think it's fine for the ER doctor to

10 call the interventional cardiologist, but the EKG

11 findings by themselves are not going to be

12 diagnostic in this case.

13 Q. Right. You said that earlier.

14 I guess when the troponins came back as

15 positive and there was another EKG, it was

16 appropriate for the emergency medicine physician,

17 Dr. Meer, to call the general cardiologist on call

18 Dr. Winekar, would that be fair?

19 A. I think it's okay, but it depends on what

20 else the ER doctor is doing for the patient. The

21 standard of care would not allow an ER doctor to

22 simply keep calling different specialists or

150

1 different physicians while delaying the

2 appropriate diagnosis.

3 Q. Okay. I understand that. My question for

4 you was, was it a deviation in the standard of

5 care for Dr. Meer to call Dr. Winekar who was the

6 general cardiologist on call?

7 A. No, it's not a deviation of standard of

8 care, but we don't know what was communicated in

9 that phone call. So if he did not communicate

10 pertinent facts of the case, then that would be a

11 deviation of standard.

12 Q. And if he did communicate the fact that

13 you believe he should have, that would have been

14 an appropriate communication?

15 A. Yes.

16 Q. Have we now covered all the opinions that

17 you have with regard to Dr. Meer?

18 A. Yes.

19 Q. Now, you also had opinions with regard to

20 Ms. Alton?

21 A. Yes.

22 Q. Let me ask you this first, do you

151

1 supervise emergency medicine physician assistants?

2 A. No.

3 Q. Do you work with physician assistants in

4 your practice of internal medicine?

5 A. I have in the past. Currently I have a

6 nurse practitioner in my office. But I currently

7 do not have a physician assistant.

8 Q. When is the last time you had one, a

9 physician assistant?

10 A. I have worked with physician assistants in

11 the hospital over the years but not for several

12 years.

13 Q. Do you believe that the standard of care

14 is the same for a physician assistant and a

15 physician?

16 A. I think the standard of care --

17 MR. SUMMERS: I objection to the form

18 and foundation of the question, but you can

19 answer.

20 A. I believe the standard of care is

21 similar. I'm not sure if it's exactly the same.

22 But the training the physician assistants receive

152

1 is certainly less rigorous than a physician, but

2 after I reviewed the testimony and the way Saint

3 Agnes has set up their ER, the physician assistant

4 appears to evaluate these patients and should be

5 held to the same standard of care in terms of

6 diagnosing a pulmonary embolism.

7 Q. What appearance do you draw on to be able

8 to comment that standard of care for diagnosing a

9 pulmonary embolism is the same for a physician

10 assistant as it is for a board certified emergency

11 medicine physician?

12 A. I think the standard of care is that a

13 physician assistant that's working in the ER in

14 evaluating a patient has to understand the signs

15 and symptoms of pulmonary embolism. Pulmonary

16 embolism is not a rare diagnosis. It should be

17 one of the leading diagnostic considerations of a

18 physician assistant working in the emergency

19 department.

20 Q. Was it appropriate for Ms. Alton to within

21 about 15, 20 minutes get Dr. Meer involved in this

22 patient's care?



39 (Pages 153 to 156)

153

1 A. Yes.

2 Q. Would you agree that as a general rule

3 that there are times when the standard of care for

4 a physician assistant would not be the same as a

5 board certified emergency medicine physician?

6 MR. SUMMERS: Objection. You can

7 answer.

8 A. My opinion is that in this case, the PA

9 working in the ER evaluating a patient like this

10 should be held to the same standard of care for

11 diagnosing pulmonary embolism.

12 Q. What's the basis of that?

13 A. This is a patient who presented with signs

14 and symptoms of a pulmonary embolism and if the PA

15 is working in the ER and evaluating patients, the

16 PA needs to understand the disease and understand

17 how to diagnose this.

18 Q. Would you outline for me the violations of

19 the standard of care committed by Ms. Alton.

20 A. Similar to what we said previously about

21 Dr. Meer, the lack of including pulmonary embolism

22 or DVT in the differential diagnosis was a

154

1 deviation of standard of care.

2 Q. Is your testimony the same as to the basis

3 of that opinion for Ms. Alton as it is for

4 Dr. Meer?

5 A. Yes.

6 Q. So in terms of the basis for your opinion,

7 all of the things you said earlier that you

8 believe apply to Dr. Meer also apply to

9 Ms. Alton?

10 A. Yes.

11 Q. Anything else that you have on your list

12 that you believe constitutes a violation of the

13 standard of care by Ms. Alton?

14 A. No.

15 Q. Would your testimony be the same as to her

16 with regard to diagnosis and management and

17 treatment as it was when you gave your opinions as

18 to Dr. Meer?

19 A. Yes.

20 Q. You said you have opinions with regard to

21 Dr. Falck, can you tell me what those are.

22 A. Dr. Falck failed to evaluate this patient

155

1 for pulmonary embolism, he failed to order

2 appropriate diagnostic studies, and may have

3 failed to communicate the appropriate information

4 to the accepting attending physician.

5 Q. Why do you say that?

6 A. Based on the deposition transcripts that I

7 reviewed, there was a question as to what

8 information Dr. Awan received from the emergency

9 department.

10 Q. Do you know what time Dr. Falck came into

11 the emergency department to begin his shift?

12 A. 11:00 p.m., approximately.

13 Q. Did you read his deposition where he said

14 he did not communicate with Dr. Awan?

15 A. Yes.

16 Q. So, it doesn't appear that Dr. Falck

17 communicated with Dr. Awan; is that fair?

18 A. Yes.

19 Q. Would it be fair to say that you've never

20 given a report as an emergency medicine physician

21 whose shift is ending to an emergency medicine

22 physician whose shift is beginning?

156

1 A. Correct.

2 MR. SUMMERS: I'm not sure he was

3 done with his opinions to Falck unless you're just

4 limiting to the time period before the code. He

5 has already testified to the code issue, I think.

6 MS. MALONE: Right. I'm going to get

7 there.

8 MR. SUMMERS: Okay. I didn't wanted

9 to end at that.

10 By MS. MALONE:

11 Q. Tell me -- before we get there -- tell me

12 the basis of your opinion that Dr. Falck who took

13 over the care of an admitted patient failed to

14 evaluate pulmonary embolism and order the

15 appropriate diagnosis?

16 A. The patient may have been admitted, but he

17 was still in the emergency department and had not

18 received appropriate care. Dr. Falck by accepting

19 the sign-out from Dr. Meer has a responsibility to

20 a patient that continues to be housed in the

21 emergency department, especially a patient who has

22 not been appropriately diagnosed and treated.



40 (Pages 157 to 160)

157

1 Q. Inasmuch as you have never worked in an

2 emergency department as an attending emergency

3 medicine physician and has never been given report

4 as an emergency medicine physician from one shift

5 to another, what in your experience allows you to

6 say what an accepting attending physician in the

7 emergency department should or shouldn't do with

8 regard to an admitted patient?

9 A. Counsel, I may not be an emergency

10 medicine physician, but I have spent 15 years in

11 the emergency department admitting patients. I

12 have witnessed the verbal communication that

13 occurs between ER physicians on sign-out. I

14 perform sign-out myself with other doctors in my

15 group, so I'm aware what a sign-out should

16 entail. And the basis of my opinion is that a

17 patient who presents with tachycardia, hypoxia and

18 all the other findings that we've previously

19 discussed, that needs to be communicated from ER

20 doc to ER doc. And the opportunity to perform a

21 diagnotic test was still there. Just because the

22 patient was admitted doesn't mean that there was

158

1 no longer the opportunity to save this patient.

2 This was a patient who was in the ER for

3 approximately nine hours before he had a massive

4 pulmonary embolism and PEA arrest. So I look at

5 this case as a global systemic failure among all

6 the physicians that were involved.

7 Q. Let me talk to you a little bit about some

8 testimony you gave earlier with regard to a

9 patient who's admitted. When you agree to accept

10 the patient on your service for an inpatient

11 admission, for an unattached patient as you have

12 testified earlier, is it your understanding that

13 the responsibility for the admitted patient's

14 medical care then rests with the accepting

15 admitting physician as a medical emergency?

16 A. Are you asking me if the patient is still

17 in the emergency department?

18 Q. Yes. What I'm asking you is, once the

19 patient has been admitted and accepted by the

20 attending and/or the admitting team, whoever that

21 might be, you would agree with me, I think, that

22 the admitting and/or accepting attending can give

159

1 orders or suggestions to the emergency medicine

2 attending as they discuss the admission of the

3 patient; is that fair?

4 A. I think those are two different

5 questions. Certainly, the admitting internist can

6 provide orders, but my opinion is that it's a

7 shared responsibility. As long as the patient is

8 still physically in the emergency department, it's

9 a shared responsibility between the ER and the

10 admitting team. Especially since some patients

11 stay in the emergency department for many hours,

12 and especially when a patient is in the ER at

13 nighttime and the attending internist is not in

14 the hospital. So I think it's a shared

15 responsibility.

16 Q. Outside of some potential policies that

17 you may look for at your hospital, are you

18 familiar with any general guidelines as to the

19 responsibility of an emergency medicine physician

20 once that patient is accepted by and admitted to

21 the service of an attending physician but is

22 awaiting an inpatient bed?

160

1 MR. SUMMERS: Are you talking about

2 guidelines that a hospital may have or not.

3 BY MS. MALONE:

4 Q. No. I'm saying outside of that, are you

5 aware of any general guidelines known to emergency

6 medicine physicians as to the responsibility of

7 the emergency medicine physician once the

8 emergency medicine patient is accepted or admitted

9 to the office of an attending physician but is

10 awaiting a bed.

11 MR. SUMMERS: Other than the standard

12 of care is that what you're asking?

13 MS. MALONE: Nope. I'm just asking

14 him if he is aware of any general guideline.

15 MR. SUMMERS: I object. You can

16 answer.

17 A. I'm aware of opinions on this matter that

18 some people say one thing, some people say the

19 other, but in terms of who's ultimately

20 responsible for the patient. But in a case like

21 this, where the patient is admitted at 11:00

22 o'clock at night, the attending internist is at



41 (Pages 161 to 164)

161

1 home, the ER has failed to perform the appropriate

2 tests and may have failed to appropriately

3 communicate the information to the accepting

4 physician, it's certainly a shared

5 responsibility. So, even if there are guidelines

6 out there that say that once a patient is

7 admitted, it's no longer the ER's responsibility,

8 I don't believe that would apply to this

9 particular case.

10 Q. Okay. I'm not asking you to say that it

11 applies to this case. I'm asking you whether that

12 is, at least, a general principle or a general

13 understanding among some that once the patient is

14 admitted to the service of an attending physician

15 the emergency medicine physician's role,

16 essentially, ends unless there is a change in the

17 patient's condition that are worse or, as you said

18 earlier, there's hemodynamic instability?

19 MR. SUMMERS: I object. That's a

20 rather longwinded, compound question, and I also

21 object to the form and foundation. You can

22 answer, if you can.

162

1 BY MS. MALONE:

2 Q. I can rephrase it. Would that help,

3 Doctor?

4 A. I am aware of thoughts on this topic. I'm

5 not sure that they've been widely accepted as

6 general guidelines. Obviously, the ER doctors

7 would like to, you know, say that the

8 responsibility lies on the attending -- the

9 admitting team, but I think every case is

10 different. And while there may be some guidelines

11 out there, guidelines are meant to provide broad

12 advice but don't always apply to individual cases.

13 Q. So let me just ask you this in a general

14 fashion, then, and then we can move on.

15 Would you agree with me that there is at

16 least some guideline or some discussion insofar as

17 the relationship between the emergency medicine

18 attending and the accepting attending that once

19 the patient is admitted and accepted to the

20 service of an attending physician and/or admitting

21 team, the responsibility for the patient's care

22 rests with the attending physician absent of a

163

1 sudden emergency need in the emergency

2 department?

3 MR. KRUEGER: This is Trace, I'll

4 object. That's been asked many times.

5 MR. SUMMERS: I object, too.

6 BY MS. MALONE:

7 Q. Go ahead, Doctor.

8 A. I'm aware that that literature exists, but

9 as I've said several times, I don't agree with

10 it.

11 Q. Have you ever placed a call as an

12 attending in the emergency department to a

13 physician on call to the emergency department to

14 see if he or she will accept the patient?

15 A. You're asking me have I ever placed a call

16 as an attending ER doctor, the answer would be no.

17 Q. Yes.

18 A. The answer's no.

19 Q. Have you ever intervened as an emergency

20 medicine physician in the care of an admitted

21 patient who is boarding in the ED and his

22 condition suddenly deteriorates?

164

1 A. Again, if you're asking me as an ER

2 physician, the answer is no.

3 Q. Now, going back to Dr. Falck. What's the

4 basis for your opinion that he failed to evaluate

5 the patient for the possibility of PE and order

6 appropriate diagnostic studies?

7 MR. SUMMERS: Other than what he said

8 several times already?

9 BY MS. MALONE:

10 Q. This is a little bit different, Doctor,

11 because Dr. Falck came in, correct, once the

12 patient had already been admitted and was

13 receiving report from Dr. Meer; is that your

14 understanding?

15 A. Yes. The basis of my opinion is that the

16 patient still had tachycardia, had been in the ER

17 for several hours but had not been evaluated

18 appropriately. And so as the next ER doctor, he

19 was accepting responsibility for the patient's

20 that were in his emergency department.

21 Q. Are you going to be testifying as to what

22 the communication should have been between



42 (Pages 165 to 168)

165

1 Dr. Meer and Dr. Falck even though you have not

2 done that yourself as an emergency medicine

3 physician?

4 A. It's my opinion that the standard of care

5 requires all physicians regardless of their

6 specialty to communicate pertinent information

7 about a patient's case. So the answer to your

8 question is yes.

9 Q. Is your testimony the same as it was

10 earlier as to what should have been communicated

11 from Dr. Meer to Dr. Falck and I would be

12 referencing what you believe should have -- what

13 you believe the standard of care would have

14 required as to a communication between Dr. Meer

15 and Dr. Winekar and/or Dr. Dua? If it's

16 different, you need to let me know.

17 A. I'm sorry, Counsel, I didn't follow that

18 question in terms of what you're asking me.

19 Q. I was just trying to shortcut matters.

20 Can you tell me as a board certified internist

21 what you believe the standard of care required of

22 a board certified emergency medicine physician

166

1 such as Dr. Meer to communicate to Dr. Falck at

2 change of shifts?

3 A. All pertinent clinical data. Specifically

4 in this case, the tachycardia, hypoxia, abnormal

5 chest X-ray, abnormal EKG, positive cardiac

6 enzymes, they all should have been communicated,

7 along the clinical history of chest fluttering.

8 Q. Had you completed your answer?

9 A. The only other thing that I think should

10 have been communicated was the patient had a

11 recent ankle injury and was immobilized. My

12 answer essentially is, all pertinent information

13 to this case should have have been communicated

14 from ER doctor to ER doctor.

15 Q. I understand that, but is the list that

16 you gave me complete?

17 A. As far as I can tell, yes.

18 Q. Would it have been appropriate for Dr.

19 Meer to tell Dr. Falck that this patient had been

20 admitted to the service of Dr. Awan and would be

21 going to the IMC once a bed was available?

22 A. Yes.

167

1 Q. Now, with regard to any other violations

2 of the standard of care, as to Dr. Falck, what are

3 those, if any?

4 A. Beyond the failure to diagnose pulmonary

5 embolism, the 20-minute delay that occurred from

6 cardiac arrest until intubation would be a

7 violation in the standard of care.

8 Q. Is it your understanding that during the

9 time from the arrest until the intubation

10 occurred, this 20 minutes that you're referring

11 to, the patient was undergoing ventilation by

12 bag mask?

13 A. Yes.

14 Q. Can bag mask ventilation be an appropriate

15 way of ventilating a patient while intubation is

16 being done or attempted to be done?

17 A. It can be, but in this case it was not

18 effectively oxygenating the patient, and that's

19 based on Mr. Falck's testimony that the pulse ox

20 was in the 80s. I've witnessed attempts at

21 intubation and what typically happens is, as

22 physicians search for the vocal cords and try to

168

1 intubate the patient, the chest compressions are

2 placed on hold, and often the ventilation efforts

3 are not optimal. And we know from Dr. Falck's

4 testimony that this patient's oxygenation was not

5 sufficient to perfuse his brain.

6 Q. He didn't say that this was not sufficient

7 to perfuse the patient's brain, did he?

8 A. No. But he said the pulse ox readings

9 were hanging around the 80s.

10 Q. Later he said they were intermittently in

11 the 80s, didn't he?

12 A. I'm not sure, but -- I'm just not sure.

13 Q. But I think you would agree with me that

14 it's not always possible to have an intubation on

15 the first attempt; would that be fair?

16 A. Absolutely.

17 Q. While the providers are attempting to gain

18 intubation for a patient, it's certainly

19 appropriate to ventilate the patient using a bag

20 and a mask; would that be fair?

21 A. That's fair. And I'm not objecting to the

22 use of a bag mask while they're trying to



43 (Pages 169 to 172)

169

1 intubate. My opinion is that it shouldn't have

2 taken 20 minutes to intubate a patient in the

3 emergency department. The person either should

4 have been intubated immediately or anesthesia

5 should have been contacted. And the fact that

6 there were two equipment failures is another

7 violation in the care of this patient.

8 Q. You're not saying that Dr. Falck was

9 responsible for an equipment failure, are you?

10 A. I don't know who's ultimately responsible

11 for equipment failure. I know that they point the

12 fingers at each other in the deposition testimony.

13 Q. Who pointed fingers?

14 A. From what I remember, there was a

15 discussion about respiratory therapy should have

16 maintained the equipment properly. Regardless,

17 the patient went into cardiac arrest at 5:30 and

18 was not intubated until 5:50. So for 20 minutes

19 he was not properly intubated.

20 Q. Let me ask you this, are you going to be

21 expressing an opinion to a reasonable degree of

22 medical probability as to whether or not the

170

1 patient had been intubated sooner, he would have

2 survived his disease or surviced the embolus? In

3 other words, was the alleged failure to intubate

4 sooner the cause of his failure to survive?

5 A. I think it was a contributing factor, but

6 I'm not sure to what degree. This patient was

7 able to be rescued from his condition up until the

8 time of the cardiac arrest. I think the 20-minute

9 delay in intubation contributed to his ultimate

10 outcome.

11 Q. But my question is, let's -- first of all,

12 are you going to be quantifying at what point

13 during the 20-minute period this would have made a

14 difference to have him intubated sooner?

15 MR. SUMMERS: I object. That was

16 covered rather extensively by Shannon.

17 BY MS. MALONE:

18 Q. I guess the answer was no; am I right?

19 A. My opinion is that after a few minutes of

20 low oxygen levels, the brain tissues starts to

21 die. So every passing minute is a worse prognosis

22 for the patient. But I can't give you any detail

171

1 beyond that.

2 Q. Let me just ask you again, if the

3 intubation had occurred earlier than 20 minutes,

4 is it going to be your testimony that this patient

5 would have survived? In other words, would the

6 earlier intubation have changed the outcome so

7 that Mr. Jacobs would have survived this disease?


9 answered.

10 A. I view it as a contributing factor, but I

11 can't place a percentage on the amount that it

12 contributed to his outcome.

13 Q. Any other deviations in the standard of

14 care for Dr. Falck?

15 A. No.

16 Q. By the way, what's basis of your opinion

17 that the pulse ox being in the 80s intermittently

18 for 20 minutes caused him to have cerebral

19 hypoxia?

20 A. A pulse ox in the 80s, especially the low

21 80s would typically not be sufficient to perfuse

22 the brain, especially in a patient who was not

172

1 used to suffering hypoxic episodes. Some patients

2 who are chronically hypoxic may do better. But a

3 patient like this who should be in the high 90s

4 and is suddenly somewhere in the 80s is at risk

5 for brain injury.

6 Q. Did the fact that he had a saddle embolism

7 in his lung affect his ability to be ventilated?

8 A. Yes.

9 Q. So, is it surprising to you that he was

10 intermittently in the 80s during this 20-minute

11 period on the account of the fact that he had this

12 saddle embolus sitting in the vessels of his

13 lungs?

14 A. No, it doesn't surprise me. And that's

15 one of the basis of my opinions why the pulse ox

16 of 91 percent nine hours earlier was such a

17 critical vital sign that required a diagnostic

18 workup.

19 Q. Do you have, on your CV, any other items

20 where you have talked about diagnosis, management

21 and treatment of PE other than the two letters to

22 the New England Journal of Medicine?



44 (Pages 173 to 176)

173

1 A. If you look under lectures and courses, I

2 have over the years provided lectures on pulmonary

3 embolism to medical students and residents. I've

4 directed national courses for physicians that have

5 included material on thromboembolic disease. So,

6 yes, there are other places on my CV that would

7 indicate that.

8 Q. Are any of those being currently reduced

9 to writing?

10 A. I'm not sure I understand what you mean by

11 that.

12 Q. Do you have any power points, written

13 lectures on the care, management, treatment and

14 diagnosis of a patient with a PE or a DVT?

15 A. Yes, I do have power points. I give a

16 yearly lecture to the residents on perioperative

17 medicine, which is the medical management of the

18 surgical patient. And approximately one-third of

19 that lecture is devoted to how to prevent

20 thromboembolic disease.

21 Q. Can you print that out and provide it to

22 Mr. Summers.

174

1 A. Yes.

2 Q. I have more questions for you, but I'm

3 trying not to repeat what you've been asked

4 already.

5 Are you responsible for teaching

6 physicians who are in a residency program for

7 emergency medicine?

8 A. I am responsible for teaching physicians

9 who are in an ER residency who rotate on my

10 service. And we also have a combined internal

11 medicine/ER residency in our hospital.

12 Q. Are you responsible for teaching physician

13 assistants who are dedicated to the emergency

14 department?

15 A. No.

16 Q. Would you agree with me that definitive

17 diagnoses for a patient's clinical presentation

18 are not always made in the emergency department?

19 A. Yes.

20 Q. Would you agree that many times a

21 definitive diagnosis for a patient's clinical

22 presentation are made once the patient is admitted

175

1 to the hospital and an ongoing investigation is

2 completed?

3 A. Yes.

4 Q. And I know you're not an emergency

5 medicine physician but let me ask you whether or

6 not you agree that the standard of care does not

7 require that an emergency medicine physician

8 always reaches a definitive diagnosis as to the

9 the cause of a patient's clinical presentation in

10 the ED?

11 A. I would agree with that, as long as we're

12 not referring to this case specifically.

13 Q. We're talking about a general principle,

14 Doctor.

15 A. Yes.

16 Q. I think you may have answered this earlier

17 but let me just ask you, have you ever had case in

18 which a DVT, PE developed in an otherwise healthy

19 19-year-old as a consequence of an ankle sprain?

20 A. I have seen cases of young adults who have

21 had ankle fractures or patients who have been

22 casted for possible fractures. I will say that

176

1 it's unusual just for an ankle sprain by itself.

2 But I have seen patients with more severe sprains

3 and/or fractures who are immobilized develop the

4 DVT and PE.

5 Q. And, again, that would still be very rare,

6 wouldn't it?

7 A. Again, as I said earlier, if you're

8 including all young adults who sprain their ankle,

9 then I would say it's unusual, it's less than

10 5 percent. I think if you're specifically talking

11 about those patients that are immobilized, I think

12 the incidence is higher but still uncommon.

13 Q. Do you know what a sugar tong splint is?

14 A. I do not know specifically what it is, no.

15 Q. So, my guess is, you wouldn't be able to

16 tell me if Mr. Jacobs had such a splint whether or

17 not there would be partial immobilization of his

18 ankle?

19 A. From the review of Bridgett Johnson's

20 testimony, I gained an understanding as to what

21 the splint was doing for the patient and, more

22 importantly, what the patient was doing in the few



45 (Pages 177 to 180)

177

1 days before he presented back to the ER.

2 Q. My question is a little bit different. Do

3 you know from your own personal knowledge as to

4 the degree of mobility that the placement of a

5 sugar tong splint allows vis-a-vis the ankle

6 joint?

7 A. No.

8 Q. If we were to create a list of signs and

9 symptoms or findings consistent with the postictal

10 period following a seizure, could confusion be on

11 the list?

12 A. Yes.

13 Q. Could slowed speech be on the list?

14 A. Yes.

15 Q. Could slow response to questions be on the

16 list?

17 A. Yes.

18 Q. Would you agree with me that a postictal

19 state may last from seconds to minutes to hours

20 following a seizure?

21 A. Yes. Typically it lasts minutes, but it

22 could last hours, yes.

178

1 Q. Certainly as you testified to earlier, it

2 was reasonable to include seizure in a

3 differential diagnosis of this patient?

4 A. Yes.

5 Q. Can we agree that the definitive cause of

6 a new onset seizure is not always determined in

7 the emergency department?

8 A. That is correct.

9 Q. Is it fair to say that many cases of

10 epilepsy do not have an identifiable cause?

11 A. That's correct. Although I wouldn't

12 associate the term epilepsy with this case.

13 Epilepsy is a diagnosis after an extensive

14 evaluation. This is merely a patient who presents

15 with seizure or seizure-like activity.

16 Q. Right. But what I'm saying is, ultimately

17 after a diagnosis of new onset seizure, there are

18 certainly circumstances where if it's a primary

19 epileptic seizure, an identifiable cause is never

20 found?

21 A. That's correct. Keep in mind that seizure

22 in an adult for the first time should be

179

1 considered a sign or symptom of some other

2 condition. So the ER has the responsibility to

3 perform the initial workup to determine the cause

4 of the first unprovoked seizure.

5 Q. Right. And the first unprovoked seizure

6 can be caused by a whole host of things, not only

7 primary epilepsy but a reactive epilepsy to some

8 other kind of condition of which there are many,


10 A. Yes.

11 Q. Would you agree with me that seizures not

12 caused by a pulmonary embolus can cause skeletal

13 muscle damage, rhabdomyolysis and increase in

14 lactic acid?

15 A. Yes.

16 Q. Would you agree that the clinical

17 presentation of pulmonary embolus is variable and

18 nonspecific, making accurate diagnosis difficult?

19 A. It can be a challenging diagnosis, but I

20 don't think in this case -- I would not

21 characterize this case as a challenging diagnosis

22 for pulmonary embolism.

180

1 Q. Right. I was asking you a general

2 question. Would you agree generally that the

3 clinical presentation of a pulmonary embolus is

4 variable and nonspecific, making accurate

5 diagnosis difficult?

6 A. I agree that in some cases but not in all

7 cases is the diagnosis difficult.

8 Q. I think you said earlier that shortness of

9 breath at rest or with exertion is a very common

10 symptom of a pulmonary embolus; is that right?

11 A. Yes.

12 Q. Would you disagree with me if I were to

13 tell you that many studies have found that

14 73 percent of patients with PE have shortness of

15 breath at rest or with exertion?

16 A. I'm not sure which study you're referring

17 to. I'm sure there are others that may have a

18 different number of patients who report shortness

19 of breath. The point is that not all patients

20 with pulmonary embolism have shortness of breath.

21 So you can't rely on the patient telling you that

22 they're short of breath to make the diagnosis.



46 (Pages 181 to 184)

181

1 Q. Well, I think we can certainly agree that

2 the majority of patients who have an acute

3 pulmonary embolus complain of shortness of breath;


5 A. I think so, but as I spoke about earlier,

6 the degree of pulmonary compromise often is

7 determined by the patient's underlying pulmonary

8 status. So I'm not sure how many 19-year-olds

9 were included in the study that you're

10 referencing.

11 Q. I know you talked about pleuritic chest

12 pain earlier but if we were to create a list of

13 common signs and symptoms for a pulmonary embolus,

14 would pleuritic chest pain be on the list?

15 A. It would be on the list as a symptom of


17 Q. How about cough?

18 A. It could be, yes.

19 Q. How about calf or thigh pain?

20 A. Yes. That would be a symptom of a DVT in

21 some patients.

22 Q. As well as calf or thigh swelling?

182

1 A. Yes.

2 Q. And if we were to create that list, would

3 wheezing be on it?

4 A. In my experience, wheezing could be on the

5 list but it's not a common finding in patients

6 with pulmonary embolism.

7 Q. If we were to create a list of some of the

8 most common signs seen in patients with PE, would

9 rales be on the list?

10 A. It could be but is not always and probably

11 not present in most cases.

12 Q. But it could be a common sign seen in

13 patients with PE, wouldn't you agree to that?

14 A. I would agree that it could be a sign, but

15 I wouldn't agree that it's necessarily a common

16 sign.

17 Q. How about increased breath sound?

18 A. That would also be on the list.

19 Q. Would extenuated pulmonic component of the

20 second heart sound be on the list?

21 A. It's on the list. In my experience, it's

22 a difficult sign for physicians to delineate and

183

1 is often not reported.

2 Q. What about jugular vein distension, is

3 that on the list?

4 A. Jugular vein distension is a specific sign

5 of right-sided heart failure and is not specific

6 to pulmonary embolism, but could be found in

7 patients who have pulmonary embolism.

8 Q. Would you agree with me that without an

9 autopsy it's difficult to determine the extent of

10 pulmonary embolus in the veins of a leg in this

11 case if we presume that the pulmonary embolus came

12 from the deep veins of the leg?

13 A. Without an autopsy or a vascular study of

14 the legs, we do not know the answer to that.

15 Q. Assuming that the pulmonary embolus came

16 from the leg, is it possible to tell from any of

17 the information in the medical records how much of

18 the total clot broke free on August 20?

19 A. No.

20 Q. Assuming that a pulmonary embolus came

21 from the leg on August 20, is it possible to tell

22 from any of the information in the medical record

184

1 how much of the clot was left in the leg vein and

2 where it was located?

3 A. No.

4 Q. Can a clot burden in the deep veins of the

5 lower extremity play any role in determining how

6 effective Heparin will be in preventing the clot

7 from leaving leg and ending up in the lung?

8 A. I'm not sure how to answer that. Heparin

9 is instituted in most patients who have

10 thromboembolic disease regardless of the clot

11 burden. I'm not aware of clinical studies that

12 tell us how effective Heparin is depending on clot

13 burden. I've never seen that widely reported.

14 Q. We can agree that Mr. Jacobs was not

15 bedridden between August 17 and August 20?

16 A. He was not bedridden the whole time, but

17 based on my review of Bridgett Johnson's

18 transcript, he spent a significant amount of time

19 in bed or in the house and was much less active

20 than normal.

21 Q. So it he wasn't bedridden for three days;

22 is that right?



47 (Pages 185 to 188)

185

1 A. In other words, he did not spend the

2 entire three days in bed, that's correct. But he

3 did spend more time than usual in a lying down

4 position.

5 Q. Would you agree that patients who have

6 ankle sprains are not treated prophylactically for

7 the development of a DVT generally?

8 A. That's generally true.

9 Q. And would you agree that, generally

10 speaking, the routine use of thromboprophylaxis is

11 not suggested for patients with isolated lower

12 extremity injuries distal to the knee?

13 A. That's correct. I have no criticism of

14 the care that was provided in the initial ER

15 evaluation on August 17.

16 Q. Would the fact that one generally does not

17 use thromboprophylaxis for isolated lower

18 extremity injuries distal to the knee suggest that

19 such injuries are not thought to put a patient at

20 risk for the development of DVT or PE?

21 A. I would disagree with that. Any injury or

22 actually any medical condition that causes a

186

1 patient to spend more time than usual in bed or

2 being less active increases their risk for

3 thromboembolic disease. The decision not to

4 provide thromboembolism is based on a risk/benefit

5 ratio that takes into consideration the incidence

6 of thromboembolic episodes following an ankle

7 sprain. But it does not mean that the patient was

8 not at higher risk because of his lack of

9 activity.

10 Q. Are you able to quantify the increased

11 risk?

12 A. I would simply be able to say it was above

13 above his baseline. Beyond that, I couldn't

14 quantify it.

15 Q. Would you agree that an initial pulse ox

16 of 91 percent could be seen in a patient following

17 a seizure?

18 MR. SUMMERS: Objection to form.

19 A. I agree that a pulse ox of 91 could be

20 seen; however, I would not expect it in a patient

21 who doesn't have some underlying cardio or

22 pulmonary process occurring. This is a

187

1 19-year-old otherwise healthy patient with no lung

2 disease who was alert and oriented times four

3 according to the paramedics, and he should not

4 have been hypoxic when he was evaluated in the

5 emergency department.

6 Q. So you've never seen any comments or

7 reports in the literature that a new onset seizure

8 and including a period of time where the patient

9 is in the postictal period could produce a pulse

10 ox of 91 percent?

11 A. I'm aware that some patients can develop

12 hypoxia as a result of a seizure, but my opinion

13 in this case is that this patient's hypoxia should

14 not have been related to his seizure or

15 seizure-like activity.

16 Q. Right. And I understand that's your

17 opinion. I was asking a general question of

18 whether or not you believe that a patient who has

19 had a seizure could have a pulse ox of 91 percent

20 due to various factors associated with a seizure

21 in the absence of a pulmonary embolus?

22 A. Yes. A patient can aspirate in the

188

1 setting of a seizure. A patient could have been

2 treated with medications for the seizure. There's

3 various reasons why a patient could be hypoxic

4 following a seizure.

5 Q. Which was my next question, can a patient

6 who is noted to be drooling and foaming at the

7 mouth during seizure activity potentially aspirate

8 a small amount of mucous or saliva that could

9 result in at least a transient pulse oxygenation

10 of 91 percent?

11 A. It's possible.

12 Q. Is aspiration a potential risk in a

13 patient with seizure who does not have a PE?

14 A. Yes.

15 Q. Can a patient who is in a postictal period

16 have a period of hypoventilation?

17 A. It's possible but in this case we have a

18 respiratory rate of 14 in the setting of a pulse

19 ox of 91 percent.

20 Q. Right. I guess my general question is,

21 would a patient in a postictal period, can it ever

22 be the case that they can be hypoventilating for a



48 (Pages 189 to 192)

189

1 period of time?

2 A. Yes.

3 Q. Can a patient who is obese such as we have

4 in this case have a lower baseline oxygenation

5 level than a patient who is not obese?

6 A. If you're referencing this particular

7 patient and this particular oxygen level, the

8 answer is no. The patient's obesity would not

9 explain by itself a pulse ox of 91 percent.

10 Q. Generally speaking, can obesity affect

11 baseline oxygen saturation levels?

12 A. Not to this degree in an otherwise healthy

13 patient.

14 Q. Do you agree that Mr. Jacobs oxygen

15 saturation on two liters was in the normal range

16 from 7:45 p.m. to until about 5:30 the next day?

17 A. I would say that most of the readings were

18 improved. He had some 100 percent readings, a

19 99. He did have a 94 percent at 7:45 but after

20 that his pulse ox was improved.

21 Q. Looking just at the vital signs during

22 that same period of time, is there any evidence of

190

1 hemodynamic instability during that period of

2 time?

3 A. His heart rate was elevated during that

4 time. He had a heart rate of 108 and 110. And at

5 5:00 a.m., he was 118. So that's certainly

6 abnormal, it's tachycardic, and would suggest

7 there's some cardiopulmonary event happening.

8 Q. What is your definition of a hemodynamic

9 instability?

10 A. Tachycardia is part of that. A lot of

11 people mistakenly think that you have to have a

12 low blood pressure to call someone hemodynamically

13 unstable. But tachycardia is actually a very

14 sensitive indicator of hemodynamic instability.

15 Q. Is mean arterial pressure an indicator of

16 hemodynamic instability?

17 A. It can be.

18 Q. So, again my question is, overall, would

19 you characterize this patient as being

20 hemodynamically unstable between the time of

21 admission and the time that he deteriorated to the

22 next morning?

191


2 answered.

3 A. I would characterize him as having

4 multiple abnormal vital signs. Whether or not

5 he's hemodynamically unstable depends on your

6 definition of it. And as I pointed out earlier,

7 this patient's heart rate was significantly higher

8 than his baseline from several days earlier. His

9 pulse ox was significantly lower. So I would

10 characterize him as having hemodynamic changes

11 that were clinically significant.

12 Q. Could reasonable mind disagree as to

13 whether these vital signs over this period of time

14 represented hemodynamic instability?

15 A. I would like to talk a little bit about

16 hemodynamic instability. It refers to whether the

17 circulation is acting appropiately for the

18 patient. You can use vital signs to assess that,

19 you can place invasive lines to assess it. If a

20 patient is complaining of chest fluttering and is

21 hypoxic and tachycardic and has evidence of damage

22 to the heart, then there is hemodynamic

192

1 instability.

2 Q. So, my question was, could reasonable mind

3 disagree with you as to whether or not Mr. Jacobs

4 demonstrated hemodynamic instability during this

5 period of time?

6 A. I think if someone only looked at the

7 vital signs in isolation, that would be a major

8 mistake and it would miss the point of the case,

9 which is you have a patient who has signs and

10 symptoms of a pulmonary embolism, and you need to

11 take all of the data into consideration and not

12 solely focus on one piece of data.

13 Q. So I take it you disagree with my

14 question?

15 A. Yes.

16 Q. Can blood a pressure of 99 over 60,

17 generally speaking, be within the normal limits in

18 an otherwise healthy young adult?

19 A. It could be, but unlikely in an obese

20 male.

21 Q. Would you agree with me that hypotension

22 may be defined or generally defined as a systolic



49 (Pages 193 to 196)

193

1 pressure less than 90 or a drop in the systolic

2 pressure of 40 millimeters of mercury from the

3 baseline?

4 A. I would say that that is one definition,

5 but if a patient's baseline blood pressure was 140

6 over 80, then a blood pressure for them of 99 over

7 60 would be hypotension.

8 Q. So, it depends upon the individual

9 patient?

10 A. Yes.

11 MR. SUMMERS: Lynne, where are we

12 with this, just so I have an idea.

13 MS. MALONE: I got into this at about

14 8:00.

15 MR. SUMMERS: I'm not being critical

16 but you're going strong like it's 9:30 in the

17 morning.

18 MS. MALONE: Well -- this is off the

19 record.

20 (Discussion off the record.)

21 COURT REPORTER: Can you please state

22 your transcript order for the record.

194

1 MR. SUMMERS: Tom Summers, I want a

2 mini, four pages on one side, index, a disk, and

3 an e-tran.

4 COURT REPORTER: Thank you.

5 MS. MALONE: This is Lynne Malone.

6 I'll take the exact same thing except for no

7 disk.

8 COURT REPORTER: Okay. Thank you.

9 MS. MALONE: Do you have my e-mail

10 address?

11 COURT REPORTER: I don't think I do.

12 MS. MALONE: [email protected].

13 COURT REPORTER: Okay. Thank you.

14 Anyone else?

15 MS. MADDEN: I'll take an e-tran with

16 a ptx version, if they have that, I can print out

17 a full, mini word, and index. I do not need a

18 disk.

19 COURT REPORTER: Okay.

20 MS. MADDEN: Madam Court Reporter,

21 when that transcript comes to me, can you send a

22 PDF version, as well, with the exhibits?

195

1 COURT REPORTER: Yes.

2 MS. MALONE: Thank you.

3 COURT REPORTER: Attorney Krueger?

4 MR. KRUEGER: I would like an e-tran

5 and also a PDF condensed of the transcript because

6 sometimes my computer will not open the e-tran and

7 also a PDF of the exhibits. And if you send me

8 that stuff by e-mail, please do not send me a

9 printed copy of it. And my e-mail is

10 [email protected].

11 COURT REPORTER: Thank you.

12 (Witness excused.)

13 (Off the record at 10:00 p.m.)

14

15

16

17

18

19

20

21

22

196

1 ACKNOWLEDGMENT OF DEPONENT

2 I, MARC S. ITSKOWITZ, M.D., FACP, do hereby

3 acknowledge that I have read and examined the

4 foregoing testimony, and the same is a true, correct

5 and complete transcription of the testimony given by

6 me and any corrections appear on the attached Errata

7 sheet signed by me.

8

9

10 ________________ _________________________________

11 (DATE) (SIGNATURE)

12

13

14

15

16

17

18

19

20

21

22



50 (Page 197)

197

1 C E R T I F I C A T I O N

2

3 I hereby certify pursuant to Pa.R.C.P. No.

4 4017(d) that the witness, MARC ITSKOWITZ, M.D., was

5 duly sworn by me and that the foregoing deposition is a

6 true record of the testimony of the witness.

7 The foregoing certification does not apply to

8 any reproduction of this transcript in any respect

9 unless under the direct control and/or direction of the

10 certifying reporter.

11

12

13

14

15 ___________________________________

16 Toni S. Myers

17 Notary Public

18

19 My commission expires April 18, 2018.

20

21

22





198

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199

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200

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certify197:3certifying197:10Chair21:10challenging179:19,21chances115:17change72:7 143:10

161:16 166:2changed171:6changes19:8 78:16 79:9

79:10 91:16140:16 191:10

characterize111:3 179:21

190:19 191:3,10Charash39:1charge49:1chart42:1chest27:21 55:12

57:13,15,15,1658:5,13,15,2059:2,8,14 60:1

80:12 86:1488:9 108:22109:4,20 120:10120:17 129:2,6133:4,16 134:7134:15 135:2136:4,7 138:6146:3 147:16,17166:5,7 168:1181:11,14191:20

chief21:10 29:19choice134:13cholesterol108:11 145:7

148:14chronically172:2circle8:14circled8:19circling8:15CIRCUIT1:1circulate48:18circulation191:17circulatory60:21circumstance65:4 90:11,12circumstances93:12 178:18CITY1:1clarify7:5 30:12 47:14

51:12 106:9classic74:22clear62:18 95:18

139:10clearly75:21clinical15:19 16:16 18:1

60:4 75:5 87:991:16,21 93:1194:17,20 103:17107:20 116:19125:19 126:10145:7 146:6147:14 166:3,7174:17,21 175:9179:16 180:3184:11

clinically31:5 79:2 103:9

191:11clock97:8 124:18close48:8 115:6 116:2clot53:16 110:19,21

125:17,18 136:8136:17,20 137:4137:16 138:2183:18 184:1,4184:6,10,12

clots137:3,5 138:2coagulation104:1 106:3code56:17 57:7 92:12

92:19,20 103:21115:3 118:16120:8,14 121:3121:4 122:6123:7,10 156:4156:5

coded123:15Coe4:5Cohen45:11,16

coincide132:3collapse60:21collectively36:12College86:14 88:9combination94:16combine75:4 108:20

109:11combined174:10combining75:6come22:10 23:5 24:10

30:3,19 45:1297:22 100:5101:13 103:14110:15 120:13121:6,22 122:5

comes14:22 16:10 18:9

25:12 27:2099:17 100:13194:21

coming27:11 52:6

135:10comment152:8commentary37:16commented38:2commenting11:13comments38:5 187:6commission197:19committed128:5 153:19common



203

26:19 27:2028:1 29:2271:15 105:15,18131:4 180:9181:13 182:5,8182:12,15

commonly14:13 133:15Commonwealth2:15communicate144:22 145:8,14

145:18,21 146:1147:9,13 150:9150:12 155:3,14161:3 165:6166:1

communicated142:17 143:10,13

143:21 144:11146:4 150:8155:17 157:19165:10 166:6,10166:13

communicating143:8communication142:3,16,19,22

143:2,5 144:12146:18,19150:14 157:12164:22 165:14

communicators146:13compared67:22compensate61:18complain181:3complaining146:2 191:20complaint29:19complete39:7 47:5 166:16

196:5

completed146:9 166:8

175:2complied134:16complies8:18component182:19compound161:20compressions120:10,17 168:1comprised25:8compromise181:6computer42:4 195:6concern106:6 148:1concerned108:19concerning21:2 71:13

108:13,15 119:6concerns149:2condensed195:5condition15:20 16:17 18:1

19:8,11 26:8,926:20 27:2029:22 97:2106:22 135:11161:17 163:22170:7 179:2,8185:22

conditions28:1conference48:13confidently28:4confirmed29:10

confirming40:4confused54:14 56:12confusing69:22 71:20confusion177:10conjunction130:14Conn4:15connection37:17 41:12consenting21:16consequence175:19consider11:2 69:19 70:4

86:7 100:8130:14 131:5

consideration69:6,14 186:5

192:11considerations152:17considered40:6 83:1 131:10

131:14 179:1consistent82:8 132:14

177:9constellation130:18 132:13,22constitutes154:12consult22:20 23:14,19

24:10 77:987:10 90:8 94:198:22 106:16107:5

consultant25:15consultants24:12 107:3

consultation24:3,6 146:8consulted14:13 23:7,20

26:2 38:2042:20 62:1964:3,17,17112:22

consulting63:4 81:20 99:10

148:7consults22:21 24:8,10contact21:9contacted119:4 169:5contacting64:12contemplated50:4context145:8continue20:14continues156:20contraindications94:7contrast133:16contributed170:9 171:12contributing170:5 171:10control197:9conversation65:22 146:12,21cooperate33:19copies46:10 47:12copy7:11,13,15 9:20

9:22 10:6 36:740:1 48:12,17

195:9cords118:8 167:22Cornell11:19coronary71:7,9,22 72:5,9

72:12,14,16,2073:1,3,9 108:9

correct6:11 9:18 10:10

11:10,20 12:412:11 13:16,1713:19,20 14:3,425:16 32:17,1932:20 42:21,2243:11 45:1447:8,10 49:657:14 62:4,8,1162:12,15 63:5,664:11 66:2,3,1366:14,17,1867:5,10 73:1,673:12 76:16,1777:9 81:9 83:392:21 94:3100:14 105:8106:1 108:6111:2 112:8,11113:9,21 115:7115:10,14,16,20116:4 118:1,2119:10,11120:11,12123:13,20,21130:10 131:17132:21 135:22139:5 143:14156:1 164:11178:8,11,21185:2,13 196:4

corrections196:6correctly102:4 118:5correlate132:3



204

35:3,7,8 40:1140:20 42:11,12

cough181:17counsel29:3 33:12 35:4

40:21 42:1359:11 70:1873:18 75:20113:22 118:20132:5 139:14157:9 165:17

County49:7couple105:10 130:21

131:21 132:11132:17 140:10142:14

course33:12 38:11 42:5

42:7 93:18103:20 137:6138:18 147:3

courses173:1,4court1:1 2:14 7:19,22

8:3 35:16193:21 194:4,8194:11,13,19,20195:1,3,11

cover35:9 40:14covered41:6 46:19 48:19

130:1 141:19150:16 170:16

CPR120:11create177:8 181:12

182:2,7created42:5,7criteria84:12 85:3,21

86:17 87:7,2188:11,14,1894:12,17,20,2195:12 101:6107:20

critical172:17 193:15criticism119:8 130:7

185:13criticisms117:1CT80:12,17 81:6,12

81:21,22 82:1182:12 84:1685:10,12,1995:21 96:12,1997:14 99:7,1799:18 100:6,13100:21 109:20121:16 133:16134:7,12,14,19135:2,6,12,14136:3,7,9 137:7137:13 138:3,5138:10 140:22141:16

current6:8 14:5 36:18

37:4 41:5 76:6currently12:22 151:5,6

173:8curriculum8:7CV5:10 7:11,13,20

11:18 13:3 41:5172:19 173:6

D

D4:1,3 6:1daily70:14damage75:14 122:15

179:13 191:21Dann3:14data32:11,11 71:17

126:5 131:11166:3 192:11,12

date9:22 35:12,13

40:4 196:11dated40:4day22:13,18 56:18

70:21,21 189:16days130:21 131:12,21

132:11,17 177:1184:21 185:2191:8

deal47:17dealing23:11 76:6December40:4,13,15decision25:13 30:19 32:3

32:12 49:1887:2 89:8 90:994:15 96:16103:7 186:3

decreased120:21dedicated174:13deep183:12 184:4defect73:5defendant3:11 45:9defendants1:14 4:2,12 44:14

45:2,3 47:21defense44:18 46:3 58:17

defer87:4,8 104:11,22

105:3define78:14defined192:22,22defining10:22definition75:10 79:19

108:2 131:6190:8 191:6193:4

definitive174:16,21 175:8

178:5definitively71:10degree11:22 84:21

94:19 95:15100:19 102:7,13102:18,20 103:3103:13 114:4,17123:22 169:21170:6 177:4181:6 189:12

delay117:5,15 120:8

167:5 170:9delaying150:1delineate182:22demonstrate67:17 74:20demonstrated103:22 136:9

192:4denied57:10,13department14:14 15:1,15

16:3,7,11 18:1018:15,20 19:625:12 29:18

31:2 32:1649:17 50:3,2251:2,3 109:19116:9,21 118:22124:21 127:20135:8 142:1152:19 155:9,11156:17,21 157:2157:7,11 158:17159:8,11 163:2163:12,13164:20 169:3174:14,18 178:7187:5

depend16:16 26:7

106:22 126:18126:19

depending15:19 17:22

22:11 25:1978:14 82:698:12 135:16138:21 184:12

depends10:22 19:11

54:20 84:396:21 120:8123:9 131:8149:19 191:5193:8

depo37:12 144:5deponent6:3 196:1deposed6:4,11deposition1:17 2:1 5:9 8:1

33:6,8 35:1736:15,21 37:1837:22 38:4 40:240:5,16 41:1,1446:10 47:2,6,1257:2 73:14 74:377:7 83:12117:3 120:19



205

128:12 145:2147:5 155:6,13169:12 197:5

depositions5:13 6:17 37:9

38:2 46:14deprived122:17describe67:12described18:13 37:6description42:19 43:2 119:6designated39:12designation33:5 39:5,7despite92:18detail140:19 170:22details46:8 93:16deteriorated190:21deteriorates163:22determination63:20 97:11determine88:5 122:19

138:22 141:10179:3 183:9

determined178:6 181:7determining106:17 184:5develop52:14 54:10,11

104:9 114:8,11126:11,15 176:3187:11

developed103:22 105:2,6,8

175:18developing

113:14development185:7,20deviated130:2 143:7deviation117:6 129:11

142:11 148:22150:4,7,11154:1

deviations171:13devoted173:19DeVries3:14diabetes148:13diagnosable71:7 110:11diagnose66:15 71:9 75:18

92:22 93:21104:16 106:6153:17 167:4

diagnosed28:7 86:18 89:10

94:11 95:13111:21 112:1133:17 156:22

diagnoses66:20 174:17diagnosing26:16 105:22

152:6,8 153:11diagnosis9:16 69:9 111:5

111:13 128:7130:19 133:2136:17 150:2152:16 153:22154:16 156:15172:20 173:14174:21 175:8178:3,13,17179:18,19,21180:5,7,22

diagnostic66:12 71:22 72:3

84:18 96:5108:6,7 110:3128:8,9 130:8,9130:10 133:10134:2 137:14149:12 152:17155:2 164:6172:17

diagnotic157:21DIC104:6,9,12 105:2

105:6,8,11,12105:13,15,18106:1,5,11,13106:18,20,20

die92:8,15,17 93:3

170:21died62:4 93:7,8,9difference20:11 53:18

170:14different20:2 23:4 24:8

25:1,3,18 49:2250:1 60:18 67:868:15 73:1975:16 87:16111:6 113:6,6113:10 140:9141:1 147:22149:22 150:1159:4 162:10164:10 165:16177:2 180:18

differential69:9 73:20 111:5

111:12 128:7,11128:14,16129:15 130:19153:22 178:3

differs20:9

difficult119:15 122:18

146:7 179:18180:5,7 182:22183:9

dilated101:12Diplomate13:4direct197:9directed173:4direction107:18 197:9directly21:18 41:20disagree180:12 185:21

191:12 192:3,13disagreement137:22discharge116:4,11discovered79:22discuss159:2discussed89:14 148:11,15

157:19discussion87:12 103:3

162:16 169:15193:20

discussions33:12disease108:9 110:4

128:20 153:16170:2 171:7173:5,20 184:10186:3 187:2

disk194:2,7,18disseminated104:1

distal185:12,18distension183:2,4distinct72:21distinction53:19 54:6 79:5,7divided44:13doc81:20 119:5

147:2 157:20,20doctor6:7 8:6 18:8 23:9

25:22 29:234:13 36:1839:5 49:15 51:851:16 56:2062:2 70:8 72:277:2 83:10 95:195:19 99:21106:11 116:17117:17 118:9119:2 121:12122:13 127:2,16128:3 132:3136:14 139:13140:11 144:10147:8,10 149:9149:20,21 162:3163:7,16 164:10164:18 166:14166:14 175:14

doctors81:15 97:10

157:14 162:6doctor's148:18document39:9,11,15,16,21

68:10 130:3documentation123:11documented119:5 147:4documents



206

41:9 42:4 43:183:14,21

doing20:2 22:22 27:6

28:20 70:13103:9 149:20176:21,22

dollar43:19doppler110:11,20 134:9dopplers110:1 133:19dose91:1,5,6 97:18

98:10,11doses98:1dosing91:8 97:21 99:1

99:11 124:12Dr33:8,8 39:3 74:5

80:6 81:2 82:2117:4,22 120:20127:22,22 128:1128:5,6 129:14134:5 135:4,21139:4 141:20142:7,20 143:2143:5,5,9,10,11143:13,16,20,21144:11,11,22145:15 146:7,13146:13,18,19147:8,9,10,13147:14,20,21149:17,18 150:5150:5,17 152:21153:21 154:4,8154:18,21,22155:8,10,14,16155:17 156:12156:18,19 164:3164:11,13 165:1165:1,11,11,14165:15,15 166:1

166:1,18,19,20167:2 168:3169:8 171:14

draw152:7Drexel12:1drip90:18 91:2,15

97:20drooling188:6drop60:12,16 193:1dropped61:8,11 85:16drops61:22 86:6DS73:20Dua74:5 142:20

143:16,21144:11 145:15146:7,13,18147:13,20165:15

due115:20 187:20duly6:3 197:5DVT110:11 113:14

114:3,8 128:13129:1 153:22173:14 175:18176:4 181:20185:7,20

DVTs110:16dying97:4 112:17

115:21dynamic103:5dysfunction96:2 101:8,16

102:2,3,9,14,19103:6,14 148:4

D-dimer110:1 133:19

134:9D.C45:7

E

E3:1,1 4:1,1,1,16

5:1,7 6:1,1197:1

earlier76:4 85:18

101:21 105:10109:19 122:2124:19 125:10130:21 131:12131:21 132:11132:18 137:8139:2,13,19,22141:2,5,17146:11 149:13154:7 158:8,12161:18 165:10171:3,6 172:16175:16 176:7178:1 180:8181:5,12 191:6191:8

early22:8 56:17 69:4,5

69:8,13,15 76:376:5 83:3

earn43:18earned11:22 43:14 44:8easily49:13easy58:11 119:19echo96:22 99:7

101:19 102:11103:8 139:3141:9

echocardiogram84:19 95:22 96:8

96:17,21 99:15100:12,16,20102:1,8,17103:12,16138:16 139:15139:21 140:8,14140:17,21 141:5141:10

echocardiograms139:20echocardiograp...101:6 103:5echocardiograp...101:17 140:7echotechs97:7economic42:18ED15:10 16:13,21

17:6 19:4 21:426:3 27:14,1428:15,19 81:9139:9 163:21175:10

editors11:7educated44:1effective184:6,12effectively167:18effort117:2,22efforts168:2eight43:13 130:21

131:13either7:17 14:11 15:18

45:8 50:3 54:456:11 67:1581:19 88:8

110:2 122:8,14169:3

EKG62:20 64:15,22

66:11,16,1967:1,7,22,2268:6,9,18,19,2169:3,11,1971:10,11,17,1972:4,8 73:7 74:574:22 75:2176:3,7,12 77:3109:13 142:21145:3,4 146:5147:15 148:14149:10,15 166:5

EKGs66:5 67:15,17,20

68:1,4,14 70:570:10,12,2071:2,8,21 74:2175:2,17 76:1,10147:11

electric74:6electrical115:9electrocardiogr...96:15electrocardiogr...70:17electronic20:17 30:17

31:11,14,22electrophysiolo...60:19elevated88:2 107:9 108:1

129:3 190:3elevation68:11 69:7,11

71:11 72:6 75:276:1

elevations149:2eligibility88:17 94:21



207

95:12eligible13:12emboli53:7,11,13 54:10

89:4 110:15embolism8:13 9:16 10:13

10:18 11:3,1625:14 26:5,1726:19,22 27:627:15 28:7,9,1629:7 47:1852:13,15,1853:1,6 55:7,8,1055:19 56:1,4,957:17 58:2,7,958:18,19 59:559:10,13 60:2,860:10,15,2261:17 63:366:10,13,16,2067:2,10 71:1672:18,22 73:977:14 78:1,2,3,780:13 81:782:13,14,16,1785:16 86:1,1989:2,7,11,1790:1 92:9 93:1,393:6 94:1195:14 104:16105:22 106:7107:12,21108:13,20 109:2109:15 111:1112:17 113:3114:12 115:22122:2 125:21126:2,4,9,14128:7,9,14129:7,21 131:4132:15 133:2,17134:20 135:1136:17,19,21137:10,17,19,20138:7 141:8,17

145:10,12 148:5152:6,9,15,16153:11,14,21155:1 156:14158:4 167:5172:6 173:3179:22 180:20181:16 182:6183:6,7 192:10

embolisms59:2embolus170:2 172:12

179:12,17 180:3180:10 181:3,13183:10,11,15,20187:21

emergency13:15 14:14,22

15:15 16:3,7,1118:10,15,2019:6 25:1229:17 31:132:16 49:1650:3,22 51:2,2109:19 110:11116:9,20 118:22124:21 127:20131:16 135:8142:1 149:4,16151:1 152:10,18153:5 155:8,11155:20,21156:17,21 157:2157:2,4,7,9,11158:15,17 159:1159:8,11,19160:5,7,8161:15 162:17163:1,1,12,13163:19 164:20165:2,22 169:3174:7,13,18175:4,7 178:7187:5

EMS33:5 51:19 52:2

52:19,22 54:7enclosed35:10enclosing40:9ended112:17ends7:13 161:16England8:21 11:13

172:22enlarged109:5 129:6entail157:16entire110:19 147:14

185:2entirety52:4entitled8:21 9:7 95:7entries42:4enzymes62:21 64:15 73:8

108:3,12 109:13129:5 143:1147:15,20 166:6

epilepsy178:10,12,13

179:7,7epileptic178:19episode128:22episodes172:1 186:6equal113:15,20equipment114:21 117:10

118:4,7 169:6,9169:11,16

ER16:12 19:9,12

30:16 32:1050:11 51:1881:15,19 85:1090:6 97:10117:13,17 119:2119:5 128:22130:21 131:2132:11 135:10140:15 148:18149:9,20,21152:3,13 153:9153:15 157:13157:19,20 158:2159:9,12 161:1162:6 163:16164:1,16,18166:14,14 174:9177:1 179:2185:14

Ernest1:7 33:7Errata196:6ER's161:7especially94:5 108:20

119:22 156:21159:10,12171:20,22

Esquire3:3,13 4:4,14essentially161:16 166:12established15:1,14 17:18

18:7Estate1:5estimate26:20 44:1,2et1:13evaluate16:9 29:18

130:17 138:17148:19 152:4

154:22 156:14164:4

evaluated52:19 54:7

164:17 187:4evaluating26:16 32:7

152:14 153:9,15evaluation178:14 185:15evening22:11 124:20

134:1evenly44:17event11:5 55:3,5 60:20

61:7 85:8107:18 126:12126:15 148:3190:7

eventual85:10eventually28:7evidence53:12 82:21

84:15 100:15189:22 191:21

evident101:17evolution72:4exact18:18 26:18

27:17 29:2131:16 43:21,2244:4,15,1852:16 53:289:12 105:9114:19 194:6

exactly12:20 49:21

61:15 62:1689:19 140:13147:3 151:21

exam



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75:5examination5:2 6:5 55:13

127:14examined196:3examining104:21example76:4exchange40:21excused195:12exercise82:3exertion180:9,15exhibit5:9,10,11,12,13

8:1,6,10,1435:15,17,2236:13,15 41:743:6 46:20 47:2

exhibits194:22 195:7existing125:17exists163:8expect55:18,22 56:3

57:16 58:4,1458:18 59:4,965:15 116:9117:21 186:20

expectation57:20 58:1 82:8expected19:10experience60:5 65:11 87:1

92:21 106:13116:19 125:19126:6,10 134:18157:5 182:4,21

experienced

56:16 95:6experiences54:21expert5:13 33:6 39:6

44:12 46:11,1447:7 67:1769:19 70:1,487:3,4,9 95:7

expertise65:11 70:11,17

71:2experts39:12expires197:19explain108:1 189:9explained75:8explanations109:7,9explore95:7expressing169:21extensive178:13extensively170:16extent120:6 183:9extenuated182:19extremity62:22 110:1,16

113:2,4 128:20133:18 134:9184:5 185:12,18

e-mail40:20 194:9

195:8,9e-mails40:21 42:12e-tran194:3,15 195:4,6

F

F197:1FACP1:17 2:1,5 5:2 6:2

196:2fact47:8 119:4

129:16 143:12143:21 150:12169:5 172:6,11185:16

factor129:1 170:5

171:10factors75:6 78:1 187:20facts10:10 150:10failed128:6,7,11 130:7

154:22 155:1,3156:13 161:1,2164:4

failure60:12 61:13

104:16 158:5167:4 169:9,11170:3,4 183:5

failures169:6fair28:21 29:15

32:16 34:1741:7 67:21 98:3103:17,18131:18,22149:18 155:17155:19 159:3168:15,20,21178:9 179:9181:4

fairly18:19 29:22

44:17 66:22111:18

Falck4:3 33:8 117:4,22

120:20 127:22143:9 154:21,22155:10,16 156:3156:12,18 164:3164:11 165:1,11166:1,19 167:2169:8 171:14

Falck's167:19 168:3familiar6:15 85:21 86:2,4

159:18far29:5 37:2 48:5,8

166:17fashion93:1 162:14fast96:21 133:6fatal125:20Father1:8fault106:4fax74:5faxes42:12Federal2:6 6:9fee48:10feel57:2 70:10fees36:18,20fellows97:10fellowship70:20fewer28:18field11:16figure75:3

file33:2filed39:6filling20:4,6films41:9finalized62:6find21:6,11,18,20

30:15 31:983:15 140:8

finding67:7 71:15,16

182:5findings55:6,13 72:4

79:17 96:19103:5,17 148:14149:11 157:18177:9

fine29:13 79:16

149:9fingers169:12,13finish6:18,18finished8:18Fire33:4 51:19 52:2first6:3 35:20 37:3

39:14 49:1251:10,18 52:1462:1,3 67:2268:1,19,21 69:371:11 72:1074:4 76:1 77:379:21 80:2115:2 134:13144:12,17150:22 168:15170:11 178:22



209

179:4,5fit83:6five25:3 31:17 38:8

42:17 43:1544:6,21,22 48:9123:3

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19:3 51:1138:19,20

floors18:12fluid109:10,10fluttering57:15 129:2

133:4 146:3147:17 166:7191:20

foaming188:6focus192:12follow165:17followed97:20following54:19 56:7 78:18

80:3 140:22177:10,20 186:6186:16 188:4

follows6:4 68:7follow-ups127:9foot112:17 113:5,8,19

114:1,2,7,11foot/ankle113:15

force108:18foregoing196:4 197:5,7forget114:6forgot83:10form34:21 51:6,20

52:1 70:8 72:1374:7 105:4118:17,18125:19 136:12140:2 151:17161:21 186:18

formal40:17formalistic40:8format37:14formed52:3 62:1forms115:16fortunately112:20 114:14forward90:10found49:13 66:9

137:10 178:20180:13 183:6

foundation70:8 136:12

140:2 151:18161:21

four25:3 31:17 37:21

42:10 54:8187:2 194:2

fourth25:10fracture111:22 112:1,3,4

114:10

fractures175:21,22 176:3frame19:16 91:20

117:12 141:4free183:18frequent27:16 138:15frequently18:19Friend1:8front68:4full6:7 14:9 15:5

16:1 19:13,2022:4,5 27:2194:17

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22:14function19:17 101:2,7,15

122:22functioning101:10further84:17 99:11

105:5

G

G4:14 6:1gain168:17gained176:20gather96:13gears38:9general

12:4,8 19:5,2221:2 24:11,1324:16 25:1326:4 32:6,850:21 65:970:15,22 89:6106:21 123:2149:17 150:6153:2 159:18160:5,14 161:12161:12 162:6,13175:13 180:1187:17 188:20

generally19:1 24:13 26:7

56:8 64:1 67:2173:1 86:2,3106:10 120:12133:22 180:2185:7,8,9,16189:10 192:17192:22

generated36:8 43:9gentlemen48:18getting25:18 43:9 74:15

80:17 83:22106:5,5 135:13140:21

Gilman3:4give7:19 18:18 26:18

27:17,18,1928:10 29:2131:4 46:1152:16 53:288:11 89:9,1290:17 94:1 95:9103:7 136:15140:18 158:22170:22 173:15

given46:14 47:7 89:15

90:13 91:10,14

91:20 92:7,9,1292:13,18 93:595:13 96:5103:15 112:3124:2,11,13134:3 135:4139:13,19141:11 148:22155:20 157:3196:5

giving64:21 93:19 94:4

136:8gladly7:9global158:5globally148:20go16:11 18:2 22:13

25:4 26:10 29:229:9,14 30:132:21 33:17,2041:3,3 49:2156:21 72:2 80:583:19 95:19112:7 114:11116:17 121:11121:12 126:14138:21 139:1140:12 143:16144:6,15 163:7

goes41:13going22:3 28:22 32:21

34:13 38:1,941:3 47:5 51:951:13 56:1366:8 70:7 74:387:1 88:4 95:1497:22 100:5101:13,18 102:6103:1,14,21105:19 115:1119:21 120:13



210

121:2,5,22122:5 123:12127:3 136:7,11136:16 140:1141:8 149:11156:6 164:3,21166:21 169:20170:12 171:4193:16

gold98:13good13:2,8 34:16 35:1

120:10,16Goodell3:14gotten98:2graduated11:19 12:6granted97:13great48:16 58:7,8greater70:16group23:2 24:21 26:14

27:5 63:18,20157:15

guess35:21 68:3,16

84:11 98:6,999:7 133:11144:6,13 149:14170:18 176:15188:20

guidance65:4,8,9guideline160:14 162:16guidelines6:16 79:14 83:7

86:5,8,15 88:8159:18 160:2,5161:5 162:6,10162:11

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190:7happens167:21happy34:18hard61:5 93:16 95:4

102:10 123:11148:9

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122:3,4head45:10 98:18health20:17 22:21

30:18 38:2057:7

Healthcare1:12 3:12healthy78:6 111:2

114:10 129:19131:11 175:18

187:1 189:12192:18

hear48:1 59:7 102:3heart55:12 60:11,11

61:12,13,16,1861:20,21 68:1268:21 75:1382:21 84:1585:2,11,13,1985:20 86:1487:19 88:1,2,988:13,16,1889:5 90:7 95:495:22 96:299:18,22 100:3100:7,16 101:1101:10,12,16,20102:2,13 109:10129:3 130:12,13130:16,20 131:1131:5,9,12132:6,7,10,18133:4,6 138:17146:2 148:4,18148:21 182:20183:5 190:3,4191:7,22

held2:2 152:5 153:10help162:2helpful48:19helps141:10hematologist86:17,20,22

104:12,14,17,19105:1

hemodynamic78:15 79:9 83:6

85:8 87:21140:16 161:18190:1,8,14,16191:10,14,16,22

192:4hemodynamical...85:15 190:12,20

191:5hemodynamics82:22 91:22Heparin82:20 84:8 96:18

97:13,15,1998:2,15 99:2,899:10,11 100:11124:2,7,11125:5,12,15126:1,5,12,16126:19 137:1138:14,14141:13 184:6,8184:12

high28:3,4,8,12

104:17 108:10108:10 113:10134:21 145:6,6148:13,14 172:3

higher28:4,5,6 113:12

114:3,6 176:12186:8 191:7

highly124:16 125:18

126:10hip113:7,16,21 114:1

114:5hired46:4history75:5 112:16

145:19 166:7hold12:10 14:3 168:2home14:15,19 15:19

30:7,14,1831:15 51:2252:6 54:2 80:185:8 161:1

hospital10:14 12:4,8 14:8

14:10,16 15:2,615:17 16:217:15 18:8,1118:22 19:13,1819:20 20:10,2222:4,8,15 23:4,624:19,20 26:1127:2,5,7 28:2030:8,20 33:434:2 63:8 73:1696:10 97:4,798:20 106:12114:20 115:18115:21 151:11159:14,17 160:2174:11 175:1

hospitalist19:15,17 20:4,9hospitalists19:22 20:19hospitalization104:2hospitals133:22host58:10 179:6hour34:14 36:20,21

81:5 82:5,7 97:1135:7,12,20140:14

hours18:20 22:18 37:3

37:4 83:3 97:199:16 100:13,21140:10 158:3159:11 164:17172:16 177:19177:22

house22:18 25:3,4,7

30:20 32:4128:21 184:19

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211

hunger55:12hypercoagulable11:2 126:22hypotension86:4 87:18 88:20

192:21 193:7hypotensive104:9hypothetical84:5,22 87:7 95:5

96:11 97:12,1698:3,22 99:4,5100:20 101:14101:22 102:16103:11 125:9

hypothetically77:2 100:6

125:12hypotheticals95:8hypoventilating188:22hypoventilation188:16hypoxia52:10 54:12 56:5

57:18 58:3 60:960:17 61:1063:2 78:1679:18 85:987:18 108:21109:12 121:20123:1,3,10129:18 157:17166:4 171:19187:12,13

hypoxic79:11 119:20

142:10 172:1,2187:4 188:3191:21

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ICU16:18 17:11,16,20

18:3 106:14138:21

idea193:12identifiable178:10,19identification8:2 35:18 36:16

47:3identified11:6 41:16 42:6

42:14identify127:17identifying117:16imaging32:11 41:10

136:6 137:11138:1

IMC139:10 166:21IMCU17:13immediately52:19 68:6 169:4immobilization108:22 109:12

110:18 129:1176:17

immobilize111:19,20immobilized113:11 166:11

176:3,11importantly78:4 176:22impossible53:10improve103:6improved67:22 68:18

189:18,20improvement68:1 91:22Inasmuch157:1incidence

114:9,13 126:13126:18 176:12186:5

incident89:21include27:9 33:3 41:13

64:5 65:8 128:6128:11 133:18142:2 178:2

included128:16 129:14

173:5 181:9including10:13 27:4 42:11

114:16 129:3133:21 147:15153:21 176:8187:8

income43:14,19incontinency55:4incorporating147:19increase179:13increased61:19 68:12

130:12,13182:17 186:10

increases186:2index28:8 194:2,17indicate69:11,12 173:7indications87:14,15,16,17indicator190:14,15individual58:8 149:7

162:12 193:8Individually1:3,7individuals

117:2 127:17128:2 142:16

infarction65:2 74:18,20

75:1,8,11,12,1575:18,22 76:2,976:13

infection105:11 109:10information30:17,18 31:5

65:22 76:8142:3,8,9 145:1145:19 146:6155:3,8 161:3165:6 166:12183:17,22

initial61:6 72:8 142:19

179:3 185:14186:15

initially12:21 72:7 85:7

94:14 112:2injuries113:17 114:4,7

185:12,18,19injury51:11 63:1 69:12

71:10,13 107:16108:1 110:17111:11 113:2,8113:8,16,19,21114:1,2,3119:22 120:6,18121:9 122:9,18123:2,7 128:21142:10 166:11172:5 185:21

inpatient158:10 159:22input39:20INR98:14,16insofar162:16

instability83:6 87:22

161:18 190:1,9190:14,16191:14,16 192:1192:4

instance76:15institute93:2instituted92:15 184:9institution80:15 134:18intensive13:22 17:5intensivist26:6intensivists17:15 24:15

26:11intensivist's18:3interested34:7intermediate17:4 138:20intermittently168:10 171:17

172:10internal12:3,16,20 13:4

30:1,3 59:15,21144:18 151:4174:10

internist14:7 26:5 27:2

32:19 66:1570:2,6 81:16143:3 159:5,13160:22 165:20

internists19:19interns25:9interpret70:10,12



212

interpretation69:20 74:10

135:14 136:3interpreted81:7 141:9,16interpreting70:5,17 134:19intervened163:19intervention17:1interventional63:7,11,21 64:8

64:18,20 143:17144:16,20148:16 149:10

interventionalist64:22 149:6intracranial94:6intravascular104:1intubate117:20 118:1,9,11

119:12,19 120:1120:4 121:18168:1 169:1,2170:3

intubated117:11,13 119:1

119:14,16 121:5122:7 169:4,18169:19 170:1,14

intubating117:18 119:9intubation117:6 120:8

167:6,9,15,21168:14,18 170:9171:3,6

invasive191:19investigation107:21 175:1invoice36:5 37:3,4 39:18invoices

5:12 36:7 37:243:4

involved50:5 64:19 81:15

87:1 93:5 117:2135:5 152:21158:6

involvement30:11 62:17

72:17in-between121:4irreversible120:18 121:8

122:9 123:6isolated185:11,17isolation192:7issue66:5 156:5issues8:16 9:10 10:14

38:14 47:18items8:19 11:6 172:19Itskowitz1:17 2:1,5 5:2 6:2

6:9 49:8 196:2197:4

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90:15 98:2 99:299:8 124:11137:1 138:14141:13

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33:7 38:3,4 54:256:14 57:6 61:362:4 71:8,2173:4 74:19 75:7

77:12 78:1179:14 86:1887:6 94:1095:11 104:12105:1 107:22115:19 116:1121:7 123:6124:11 127:19132:20 171:7176:16 184:14189:14 192:3

January1:19Jehangir4:2Job1:20Johnson1:3 33:7 38:3,7Johnson's176:19 184:17joint177:6Jon4:3Jones4:15journal8:21 11:9,14

172:22judgment102:22 103:4jugular183:2,4July36:3 39:16

K

Kareem1:5,9 54:2 56:14

107:22keep29:11 46:10

47:16 72:396:18 103:4,20127:4 141:7149:22 178:21

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29:13 124:17kept126:3kind42:18 43:2 50:17

179:8King4:5knee113:7,16,21 114:5

185:12,18knew62:7know7:6 18:17 19:2

21:21 28:1631:16,18,2133:21 34:15,2136:2,4 39:1,3,1239:17 40:5 44:444:15,18 48:6,949:14 51:853:10 58:2159:15 61:5 64:965:21 67:12,2069:15 73:1174:9,12,1675:20 77:8 79:879:10,15,1683:13,15 84:1191:11 92:5 95:295:3,6,10 97:2098:13 102:11,15102:19 103:10103:19 104:7105:7 110:16112:2 114:9,19118:3 121:15123:11 126:13126:17 129:18131:19 135:21137:2 146:20147:3 148:10150:8 155:10162:7 165:16168:3 169:10,11175:4 176:13,14

177:3 181:11183:14

knowing6:15 34:7 137:7knowledge123:2 177:3known58:7 104:10

108:9,9 132:17132:17 138:10146:12,19 160:5

knows105:6 126:17Krueger4:14 139:8 163:3

195:3,4

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91:16laboratory32:11labs75:5 133:8

138:16lack130:4 153:21

186:8lactic179:14large53:15largely115:20laryngeal118:15lasts177:21late30:9 92:16 125:2latest97:2 99:16

141:17Laura4:3 33:9lawyers45:14



213

leading152:17leads149:3leakage108:3learned117:4leave128:21leaving184:7lecture173:16,19lectures173:1,2,13led136:22Leech3:14left61:20,21 73:20

74:2 184:1leg110:21 111:11

183:10,12,16,21184:1,7

legal70:1legally40:5legs183:14lethal97:2 126:11letter5:11 9:6,13 10:11

35:9,12,13,2140:3,9,13,14

letters8:20 11:6,12

42:11 172:21let's24:19 44:11 99:5

124:13 143:16147:7 170:11

level

62:16 129:4148:1 189:5,7

levels18:12 77:3,21

170:20 189:11license12:10licensed12:13lies162:8life-threatening135:11light118:7,14,14likelihood124:15likewise7:8limit135:19limited17:1 65:16

104:15limiting113:5 156:4limits192:17line74:16 90:17,20,21lines191:19Lisbon39:3list5:13 46:13,16

129:8,18 143:12154:11 166:15177:8,11,13,16181:12,14,15182:2,5,7,9,18182:20,21 183:3

listed39:17listen31:8 105:3literature

38:10,18 42:1859:16,22,2260:3,5 79:5,886:13 116:12,16116:17,18 131:7163:8 187:7

liters77:15,19 78:8

189:15little29:1 40:8 43:9

78:8 140:5158:7 164:10177:2 191:15

lived93:6,8LLC3:4 4:13LLP3:14 4:5located137:5 138:2

184:2log30:17 31:11,13,22logistical32:22long10:19,21,22 11:1

19:12 31:1348:2 54:1976:21 80:1991:10,12,13,1592:4 96:7,20119:2 123:9135:14 140:22159:7 175:11

longer31:17 120:15

121:8,21 122:8138:18 158:1161:7

longwinded29:1 161:20long-term9:7 10:3,9,16look

38:14 72:8 84:9103:21 130:20131:20 158:4159:17 173:1

looked39:11 192:6looking11:18 13:3 51:19

84:4 91:15,21127:2 131:8189:21

looks88:3 101:10lot112:21 140:5

190:10low27:22 52:10

77:12,18 114:13129:4,5 170:20171:20 190:12

lower62:22 110:1,16

113:2,4,20128:20 133:18134:9 184:5185:11,17 189:4191:9

lung172:7 184:7

187:1lungs61:17 109:11

136:10 137:3,4172:13

lying185:3Lynne4:4 51:6 193:11

194:5

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M1:9 4:3Madam194:20Madden3:13 5:3 6:6 8:4

21:22 22:234:16 35:1,2,1435:19 63:1574:13,14 76:2077:1 80:22 81:498:7 139:12140:4 144:2194:15,20

main94:5maintain28:8 51:3maintained169:16maintaining114:21major55:5 192:7majority18:2 19:10 92:22

93:2,20 110:15125:22 181:2

making9:16 49:18

179:18 180:4male69:17 111:2

192:20malfunctions117:10Malone4:4 5:4 51:5,6

74:7 80:20 81:3118:17 127:15144:7,9 146:17156:6,10 160:3160:13 162:1163:6 164:9170:17 193:13193:18 194:5,5194:9,12 195:2

[email protected]:12manage10:12 106:18

107:4management



214

127:19 154:16172:20 173:13173:17

mandate102:21mandated103:2,10manifested140:16Marc1:17 2:1,5 5:2 6:2

6:9 196:2 197:4margins42:4mark7:22 35:14 45:11

45:16 46:20marked8:2 35:18,21

36:16 43:4 47:3marker107:16Marshall3:13Maryland1:1 3:7,17 4:8,18Maryland/D.C45:7mask167:12,14 168:20

168:22masquerader58:7massive78:9,11,14,16,19

79:3,12,14,2079:21 125:20126:12,15 137:9158:3

Mateen4:12,13 33:7material41:17 173:5materials32:22 41:2,4,11

42:7,15matter

49:8 94:9 160:17matters165:19mean18:6 31:7 63:16

69:10,21 72:1987:8 111:20,21121:10 136:2157:22 173:10186:7 190:15

Meaning71:3means56:20meant51:15 162:11measurement133:6measurements98:17,19mechanically125:11mechanism85:17mechanisms60:18 61:2medical11:22 12:6 21:10

25:10 29:1431:22 33:3 34:135:10,20 37:638:14,17 40:1042:1,17 57:559:22 73:13,1584:21 86:1288:10 100:19102:7,20 124:1131:7 138:4158:14,15169:22 173:3,17183:17,22185:22

medical-legal43:15,20 44:9

70:3medications105:14,16 188:2

medicine8:21 11:14 12:4

12:14,17,2013:5,10,13,1613:22 14:1619:7 21:10 30:130:3 59:15,2164:3 131:16144:18 149:4,16151:1,4 152:11153:5 155:20,21157:3,4,10159:1,19 160:6160:7,8 161:15162:17 163:20165:2,22 172:22173:17 174:7175:5,7

medicine/ER174:11Meer4:2 33:8 127:22

128:5,6 129:14134:6 135:4,21141:20 143:5144:11 146:13146:19 147:9,21149:17 150:5,17152:21 153:21154:4,8,18156:19 164:13165:1,11,14166:1,19

Meer's143:11,20 144:22meet84:12 85:3 87:21

134:6,8members22:21memory9:15mental56:10mentioned16:2 23:15 39:5

40:8 100:10

101:21 107:9142:14

mentions39:8,9mercury193:2merely141:9 178:14merged53:22messages42:11met87:6 94:12,21

95:11midnight83:3 88:3Mike45:11mild101:7 102:14

114:1millimeters193:2mimic58:8mind29:11,13 45:12

72:4 89:2193:11 96:18103:4 124:17141:7 178:21191:12 192:2

mine99:4mini194:2,17minority67:3minute69:2 122:16

131:1 170:21minutes54:18,19 55:2

88:3 117:12119:2,3 121:19122:6,7,22

123:3 135:18152:21 167:10169:2,18 170:19171:3,18 177:19177:21

missed14:18mistake192:8mistakenly190:11mixed53:22mobility177:4moderate96:2 101:8 102:2

102:3,9,14103:6

Monday15:13monitored98:11monitoring17:3 61:6 138:15month20:20 106:15months10:20,20morning22:9 30:22 32:5

33:19 56:1778:18 80:3 83:3115:6 116:2125:3,14 137:12190:22 193:17

mother53:4,9 57:1 79:22mouth188:7move90:10 147:7

162:14mucous188:8multiple104:7,8 105:17



215

191:4muscle179:13Myers1:22 2:13 197:16myo108:16myocardial74:18,20 75:1,7

75:11,12,15,1875:22 76:2,9,12107:16,22 108:4

myocardium108:18M.D1:17 2:1,5 4:2,3

4:12,13 5:2 6:249:9 196:2197:4

N

N3:1 4:1,1,1 5:1,1

6:1 197:1name6:8 8:14,19 45:6

49:12 63:13nasal77:15,19national173:4nature41:11 42:18 43:2

148:10necessarily17:21 24:21

25:17 64:12,1882:15 104:13182:15

necessary64:11necessitate89:6need7:5,8 30:19 63:11

65:5 71:17 75:483:11 130:17145:7 149:7

163:1 165:16192:10 194:17

needed109:14 134:22

138:20 145:12needs32:13 50:7,12,14

50:18 64:7 65:188:17 118:22119:4 135:12141:6 148:17153:16 157:19

neurologic122:21neurology24:9 30:2never32:15,18 49:5

63:4 131:15155:19 157:1,3178:19 184:13187:6

new8:20 11:13 29:16

29:20 30:973:21 125:18172:22 178:6,17187:7

night30:9 125:1 137:2

141:18 160:22nighttime159:13nine34:3 47:6 158:3

172:16nomogram97:19 138:14nonresponsive54:17nonspecific75:21 78:17

179:18 180:4nonterminal92:20Nope160:13

normal68:9 69:6,16

77:20 101:7,10131:10 135:19184:20 189:15192:17

normalize78:4,7normalized77:16normally57:3 101:11Notary2:14 197:17note34:3 117:22

119:5 130:3noted36:5 54:7 188:6notes22:17 33:11,13,13

33:14 34:537:12,15,1738:5 42:3 43:8127:2

notice2:13 40:1,6,17,19

41:1,3 46:1947:5 48:20

noticed53:4notified62:21November45:21number18:18 26:18

27:17 28:2,6,1028:11 29:4,6,929:12,21 31:1634:17 41:5,942:3,10,17 43:143:8,13,21,2244:4,18 47:673:21 89:12106:19 114:19117:9 180:18

numerous105:12nurse151:6nurses20:16nursing17:2

O

O4:1 5:1 6:1 197:1oath55:21obese189:3,5 192:19obesity189:8,10object28:22 51:5 70:7

98:4 116:14118:17,18122:11 132:1136:11 139:8140:1 144:2,4160:15 161:19161:21 163:4,5170:15

objecting168:21objection56:19 72:1 74:7

116:5 146:14151:17 153:6171:8 186:18191:1

objective133:5observation16:17,22obtained134:5 141:6obviously102:12 147:22

162:6occasionally108:17occur

67:4 104:6occurred61:2,3 78:18

93:15 104:5109:17,18121:14 122:10125:1 135:4136:20 137:20146:12,18 167:5167:10 171:3

occurrence27:16 127:1occurring186:22occurs60:10,21 67:2,9

93:17 157:13offer51:9,13,17 56:13

67:16 98:1105:19 115:1123:12

offering62:13 66:4

104:21office14:8 15:14 20:14

20:16 27:1150:9,10 151:6160:9

Officer21:10offices2:2okay7:6,9 9:3 20:8

36:17 38:640:18 47:449:11 68:1083:9 98:8127:10 149:19150:3 156:8161:10 194:8,13194:19

old29:14 47:16 76:3

112:15



216

older112:13once64:1,16 93:17

121:17 158:18159:20 160:7161:6,13 162:18164:11 166:21174:22

ones24:1,2 93:8 134:4one-third173:18ongoing175:1onset29:16 73:21

178:6,17 187:7open18:21 47:11,15,17

47:20 48:3,5,8,9195:6

opinion10:15 50:7 51:13

51:17,20 52:1,352:8,17,2253:15 54:356:13 61:1,1262:1 64:13,1665:17,18 66:4,667:17 72:1377:11 78:1381:20 82:1084:20 95:296:14 98:1100:18 103:12104:4 105:4,19110:5,14 117:6121:12 123:12123:14,22124:14 125:6,9128:10,15129:13 132:18136:8,15 142:15143:6,11 144:10144:14 153:8154:3,6 156:12

157:16 159:6164:4,15 165:4169:1,21 170:19171:16 187:12187:17

opinions8:11 34:10 38:21

51:9 62:6,1495:8 104:22105:21 107:10115:1 122:1130:2,4 141:19141:20 142:2150:16,19154:17,20 156:3160:17 172:15

opportunity83:8 157:20

158:1opposed113:8optimal168:3options109:22 133:18

134:10order51:3 70:12 80:12

81:12,21 90:1891:13 134:6138:10 155:1156:14 164:5193:22

ordered81:22 89:22

90:12 99:7133:12 134:5,8134:14 138:17

ordering80:17 130:5orders90:11 159:1,6oriented54:8 187:2original11:12,15 68:13orthopedic

112:22orthopedics24:11orthopedist112:5,7outcome62:7 170:10

171:6,12outline128:3 138:10

153:18outlined134:3outpatient14:17outside8:22 9:12 12:14

15:9 23:12159:16 160:4

overall114:13 126:6

190:18ox120:20 132:6

145:22 167:19168:8 171:17,20172:15 186:15186:19 187:10187:19 188:19189:9,20 191:9

oxygen27:22 52:11

60:15 77:12,1577:19,21,2278:3,8 122:17129:4 170:20189:7,11,14

oxygenating167:18oxygenation77:16 78:7 168:4

188:9 189:4o'clock160:22

P

P3:1,1 4:1,1 6:1

PA6:10 153:8,14,16page5:2,9 7:13 9:1,2,6

13:3 34:3 73:1973:22 83:15,18

paged30:14pages1:21 34:8,8 194:2paginated83:18pagination73:17pain27:21 55:12

57:13,15,1658:5,13,20 59:359:9,14 60:1127:5 130:22131:13 181:12181:14,19

pains58:15palpations55:12PAMI74:16,17paramedics187:3part14:18 23:2 26:14

42:1 66:7 70:1474:4 95:17190:10

partial176:17partially136:13particular90:9 94:6 117:16

120:14 131:6137:4 141:12161:9 189:6,7

parts132:2pass

127:6passing122:16 170:21patient11:3 14:22 15:3

16:9,14,15,2017:22 18:9,1118:14 19:823:10 25:6,1125:11,14 26:3,826:13 27:14,2028:15 29:1930:10,16,21,2131:6 32:4,5,5,932:12 49:17,1950:3,7,9,12,1450:15,19 53:154:21 55:1,1155:19,22 56:4,956:22 57:9,1257:17 58:2,4,858:12,19 62:2162:22 63:2264:4,7,14 65:565:13,18 66:866:16 72:5 76:877:4,18,20 78:578:6 79:11 80:581:6,8,16,1883:2 85:3,7 86:686:18 87:5,1388:5,12,17,2089:2,9,22 90:691:13 92:1,1392:16 93:1996:4 97:3,5 98:298:12,21 99:3,499:5,6 103:9,15106:1,4,12,22108:9,15 109:1109:14 110:10110:17 111:4,7111:19,21112:15 113:1,19114:16 115:5,13116:8,10 117:10117:13,19,20



217

118:1,21 119:10119:19,20 120:2120:4,6,9,15121:5,14 122:7122:16 124:1,14124:17,19126:18,21128:19 129:8,16129:20,21 131:3131:11,14,21132:10,20 133:3133:7 135:7,10135:21 138:11138:13,18,20139:1,4 141:6141:22 142:9143:3 144:21145:11,17,19148:3,12,17,19149:20 152:14153:9,13 154:22156:13,16,20,21157:8,17,22158:1,2,9,10,11158:16,19 159:3159:7,12,20160:8,20,21161:6,13 162:19163:14,21 164:5164:12,16166:10,19167:11,15,18168:1,18,19169:2,7,17170:1,6,22171:4,22 172:3173:14,18174:22 176:21176:22 178:3,14180:21 185:19186:1,7,16,20187:1,8,18,22188:1,3,5,13,15188:21 189:3,5189:7,13 190:19191:18,20 192:9193:9

patients10:12,13 14:10,12

14:13,16,2115:14,17 16:2,616:10 17:6,8,1918:2,5,7,19 19:120:12,13,15,2221:2 22:16,1723:1,3,5,5,6,823:12,15 24:1,424:18,21 26:126:21 27:1,3,4,827:8,10,11 28:628:17 29:6,8,929:16 30:550:21 51:454:10,17 55:1058:14 59:1,5,959:12,13 63:1067:3,4,9 76:1089:13 92:6,8,1792:22 93:3,5,20104:8 106:12,14106:15,17 107:1111:16 112:9,12112:21 113:1,15113:16,21 114:6114:7,10 115:18115:21 116:8118:9 119:13,14119:17 123:3125:20,22 126:3126:9,11,14152:4 153:15157:11 159:10172:1 175:21176:2,11 180:14180:18,19 181:2181:21 182:5,8182:13 183:7184:9 185:5,11187:11

patient's18:1 19:8,11

31:10 41:2249:20 51:10,2152:5,9 53:4 57:1

60:12 82:22103:20 120:20124:15 130:20140:15 145:21146:1 148:1152:22 158:13161:17 162:21164:19 165:7168:4,7 174:17174:21 175:9181:7 187:13189:8 191:7193:5

pattern66:22,22 67:2,4,9

67:13,18 69:1371:11,13 74:22

Paul4:6pause83:12pausing127:4PA-C4:3Pa.R.C.P197:3PDF194:22 195:5,7PE25:20 28:2,11

29:5,10 58:1258:15 67:3,5,777:18 78:9,1178:14,15,16,1778:19,21 79:479:12,14,20,2180:2 81:2287:11,22 88:688:12 91:1492:17 93:19,21108:6,7 109:20113:14 128:11128:16 129:14130:10,15,17,19133:9 164:5172:21 173:14

175:18 176:4180:14 182:8,13185:20 188:13

PEA115:6,13,17 116:1

121:14,18 122:3123:7,17 125:13137:21 158:4

peer-reviewed11:9,11pending18:15 47:11Pennsylvania1:18 2:7,15 12:11

12:14people117:9 160:18,18

190:11percent66:21 114:15,18

115:19 132:7145:22 172:16176:10 180:14186:16 187:10187:19 188:10188:19 189:9,18189:19

percentage43:18 171:11perform128:8 130:8

157:14,20 161:1179:3

performance143:11performed96:1 99:16

100:12 133:11133:12,15,15134:22 135:7141:9

performing134:19perfuse61:20 168:5,7

171:21perfusion

60:14pericarditis69:12 108:17period16:4 54:18 80:21

103:19 119:21121:11,20 156:4170:13 172:11177:10 187:8,9188:15,16,21189:1,22 190:1191:13 192:5

perioperative173:16peripheral90:21permanent119:21permission127:6permitted67:16person64:9 117:18

169:3personal1:4 177:3personally16:20pertain8:10,12 9:9pertinent145:1,18 150:10

165:6 166:3,12pharmacy90:19phone14:14 42:11 80:6

109:17 139:3150:9

physical55:13physically19:3 80:18 81:9

159:8physician15:2 31:2,4 32:15



218

64:17 81:12,1481:20 82:186:15 120:1128:1 131:16144:17,17 149:4149:16 151:1,3151:7,9,10,14151:15,22 152:1152:3,9,11,13152:18 153:4,5155:4,20,22157:3,4,6,10158:15 159:19159:21 160:7,9161:4,14 162:20162:22 163:13163:20 164:2165:3,22 174:12175:5,7

physicians39:10 80:12

81:17 87:1388:10 104:20142:4 145:17150:1 157:13158:6 160:6165:5 167:22173:4 174:6,8182:22

physician's161:15picture147:14piece192:12Pittsburgh1:18 2:7 6:10

46:6place171:11 191:19placed144:12 163:11,15

168:2placement177:4places131:9 173:6

plaintiff39:6 42:13 44:17

45:5,8,17 46:2plaintiffs1:10 3:2 33:5

35:4 38:1840:12,21 44:1345:1,14 47:2173:18

play10:10 107:10

184:5please6:7 9:20 21:12

29:11 33:2036:13 46:2173:16 128:3139:7 193:21195:8

pleuritic57:16 58:5,13,15

58:20 59:2,8,1460:1 181:11,14

point34:16 37:5 60:13

80:10 81:995:22 120:13,14121:2,3,6,6,7,13122:19 135:3137:18,20169:11 170:12180:19 192:8

pointed107:17 146:11

169:13 191:6points173:12,15policies21:1,11 159:16portion39:8portions137:3posed50:6position60:1 94:18 95:15

99:22 101:14116:13 118:21132:5 185:4

positive62:20 64:15

71:12 73:875:10,14 108:2108:5,12,14110:2,7,9134:11 143:1147:15 149:15166:5

possibilities105:10possibility164:5possible16:19 21:17

28:11 49:1755:15,17 59:3109:7,9 119:1168:14 175:22183:16,21188:11,17

possibly16:14 84:8postictal54:9,14,16,22

55:5 177:9,18187:9 188:15,21

posts98:13post-it33:14 34:3,5

37:15,16 38:5post-its33:15,22potential28:18 159:16

188:12potentially15:18 29:18

50:10 188:7power173:12,15practice12:7,13 14:6,7,17

20:13 23:2,524:2,18,2126:14 27:470:14 87:10112:11,14 151:4

practitioner151:6preliminary33:5 97:11preparing39:20prescribed89:21present3:9,19 4:10,20

67:1 182:11presentation108:12 174:17,22

175:9 179:17180:3

presentations8:10presented25:19 85:7

124:19 132:11132:20 133:3140:17 153:13177:1

presenting29:19 63:1 131:4

135:8presents72:5 111:4 129:8

157:17 178:14pressure60:13,16 61:9,11

61:19,22 84:285:17,18 86:6108:10 129:4145:6 148:13190:12,15192:16 193:1,2193:5,6

presume122:4 147:10

183:11pretend

74:3prevent97:3 173:19prevented125:13preventing184:6previously111:1 147:12,18

148:15 153:20157:18

primarily25:20 87:18

145:2primary14:11 25:21,22

26:15 88:13117:17 178:18179:7

principle161:12 175:13print173:21 194:16printed195:9prior52:19 53:7,13

116:7 121:15128:22 131:20

private23:2 27:4,10 50:9privileges12:7 118:11probability84:21 94:19

95:16 100:19102:7,20 124:1169:22

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44:16 47:1548:9 89:13,14103:12 104:14105:14 114:15114:18 182:10

problem25:16 28:18,18



219

81:17proceduralist64:18procedure64:5process6:16 66:7,8

186:22produce187:9profile113:7prognosis170:21program174:6prolong106:10prolonged54:9prolonging127:5prominent68:12properly142:4 169:16,19prophylactically185:6proposition81:1protocol91:18 98:8,15

99:9 109:21protocolized98:19protocols124:12provide9:20,22 10:6

21:12 24:632:10 146:7159:6 162:11173:21 186:4

provided35:3 38:17 173:2

185:14provider

131:20providers38:21 57:7

142:14 146:20168:17

providing24:2 130:5prudent80:19PT98:14PTT98:11,14,16,18

138:16ptx194:16Public2:14 197:17publication9:17publications8:9,12,16 9:9published85:21 94:12PubMed38:13pull9:14 93:16pulmonary8:13 9:15 10:12

10:18 11:3,1613:18 25:1426:4,16,19,2127:6,15 28:7,928:16 29:747:18 52:13,1452:18 53:1,5,753:11,13 54:1055:7,8,10,1956:1,4,9 57:1758:2,6,9,18,1959:2,5,10,1260:2,8,10,15,2261:17 63:3 66:966:13,16,2067:2,10 71:1672:18,21 73:9

77:13,22 78:2,780:13 81:782:12,14,15,1685:16,22 86:1889:2,4,7,10,1790:1 92:8 93:1,393:6 94:1195:13 104:15105:22 106:7107:11,21108:13,20 109:2109:14 110:15111:1 112:17113:2 114:11115:21 122:2125:21 126:2,4126:9,14 128:6128:9,13 129:7129:21 131:4132:14 133:2,17134:20 135:1136:17,19,21137:10,15 138:7141:7,16 145:10145:12 148:5152:6,9,15,15153:11,14,21155:1 156:14158:4 167:4173:2 179:12,17179:22 180:3,10180:20 181:3,6181:7,13,16182:6 183:6,7183:10,11,15,20186:22 187:21192:10

pulmonic182:19pulmonologist26:6 87:11pulmonology24:12pulse120:20 132:6

145:22 167:19168:8 171:17,20

172:15 186:15186:19 187:9,19188:9,18 189:9189:20 191:9

pulseless115:9pump61:17Puntil46:6purpose26:15purposes15:16pursuant2:13 131:6 197:3pursued109:22pursuing145:16put37:1,16 145:7

185:19P-U-N-T-I-L46:6P.A4:15p.m1:19 53:3 80:7

81:2 85:1 125:1155:12 189:16195:13

Q

qualified120:1qualify84:3quantified101:3quantify186:10,14quantifying170:12question6:18 7:1 11:4

23:21 29:1,450:13 53:21

59:7,19,2068:13,16 70:870:18 71:18,1975:16 83:2295:5 96:4102:10 104:18104:19 111:6113:22 116:7121:2 122:12,14132:2 136:12139:7,18 144:5145:13 146:15148:17 150:3151:18 155:7161:20 165:8,18170:11 177:2180:2 187:17188:5,20 190:18192:2,14

questions31:9 32:22 54:1

127:3,8,9139:14 159:5174:2 177:15

quickly92:6 97:6

R

R3:1 4:1 6:1 197:1radiographic94:17radiographical94:20radiologist135:17 138:8radiology41:10,19rales182:9range16:17 26:21

27:18,19 30:444:2,3,5 55:1455:16 89:13126:21 189:15

ranges98:14



220

rare110:22 111:8,10

127:1 152:16176:5

rate68:12,21 88:2,2

129:3 130:12,13130:16,20,22131:1,5,9,12132:6,8,10,18133:4,6 146:2188:18 190:3,4191:7

ratio186:5reaches175:8reactive179:7read38:8 42:19 64:22

69:3,6 70:20,2174:4 135:18138:5 143:20147:1 155:13196:3

readily118:14 120:1,4reading67:17 71:2readings120:20 168:8

189:17,18ready8:3 47:4realize49:22 95:8really19:11 69:7 71:16

74:15 75:493:16

reason25:21 54:5 58:6

80:15reasonable81:6 82:3 84:20

94:19 95:15

100:18 102:7,20123:22 169:21178:2 191:12192:2

reasonably80:19reasons89:4 188:3receive14:14 15:3 40:17

61:21 93:21,22151:22

received37:7,10 39:15

40:12 96:3106:2 155:8156:18

receiving60:14 120:16

164:13recertified12:22Recess76:22 127:13recognition107:11recognized79:4 132:19recommend63:2recommendatio...86:5,8record20:18 30:18

31:11,14 34:1542:1 73:1683:12 183:22193:19,20,22195:13 197:6

recordings84:2records29:15 32:1 33:3,4

33:14 34:135:11,21 36:2037:6 40:10,1441:10 51:19

52:2 57:5,9,1261:7 62:18 68:773:13,15 77:7103:22 120:3126:8 132:12138:4 142:18147:4 183:17

recover92:6recovered121:17reduced101:2 110:18

173:8redundant43:10refer86:16referencing165:12 181:10

189:6referred73:17 112:5

116:7referring59:17,20 68:6

118:6 167:10175:12 180:16

refers73:2 79:9 191:16reflect57:5,9,12reflecting43:2refresh9:14regard141:20,20 142:15

150:17,19154:16,20 157:8158:8 167:1

regarding139:19 142:21,22

143:11regardless136:20 165:5

169:16 184:10

regimen97:21regular17:2 138:19related187:14relation49:11relationship162:17relative87:15,17relay142:9relayed142:4,8relevant8:15,16 10:14

21:19relied42:19rely31:4,7 138:7

180:21relying59:21 60:3

116:12,15,18,19138:4

remember46:8 78:22 89:19

90:5 91:5,6,7,1998:18 112:14169:14

remind83:11remotely31:22repeat139:7 174:3rephrase162:2repolarization69:4,5,8,13,15

76:3,5report56:11,12,15 57:1

57:4 101:7

109:5 138:4147:17 155:20157:3 164:13180:18

reported1:22 57:6 183:1

184:13reporter2:14 7:20,22 8:3

35:16 193:21194:4,8,11,13194:19,20 195:1195:3,11 197:10

reporting57:14reports41:21,22 42:10

43:8 129:2187:7

Representative1:4represented191:14reproduction197:8require15:3 26:9,11 77:4

78:3 80:14 84:7133:9 145:14175:7

required10:16,17,19 63:2

80:9,11 88:16124:7,20,22131:19 141:21147:9 165:14,21172:17

requirement86:3requirements77:22requires32:6 81:12 165:5rescued170:7research11:15



221

residency12:3 174:6,9,11resident25:9residents173:3,16respect197:8respiratory169:15 188:18respond54:18 55:1responds98:12response91:21 119:9

177:15responsibility19:6 64:4 144:22

145:18,21 146:1148:19 156:19158:13 159:7,9159:15,19 160:6161:5,7 162:8162:21 164:19179:2

responsible20:21 81:18

117:8,15,18147:13 160:20169:9,10 174:5174:8,12

rest80:8 103:16

180:9,15rests158:14 162:22result54:9 82:4,5

187:12 188:9results80:18 91:16

138:9resuscitated116:10,21resuscitation115:2 117:2

retainer49:1return121:21 123:4returned122:21returning123:18returns43:14reverse122:12revert77:20review30:18 31:11,14,22

33:12 34:936:20 37:1741:19 42:5,848:1 52:4 61:783:8,11 86:12132:12 138:3176:19 184:17

reviewed37:5,9 39:16

41:12,17,20,2142:19 60:5 62:374:2 117:3128:12 152:2155:7

reviewing36:19 43:3reviews38:10 68:10

83:14,21rhabdomyolysis179:13rhythm69:7 74:6right7:14 21:19 60:11

60:11 61:12,1261:16,18 65:668:4 72:2182:21 83:1984:15 85:2,1185:13,18,20

87:19 88:13,1688:18 89:5 90:795:4,21 96:1,1596:19 97:1498:5 99:18,21100:3,7,15101:1,2,10,12101:15,20 102:2102:3,9,13,19103:13 113:6131:16 138:17139:16 141:12143:18 146:22148:4 149:13156:6 170:18178:16 179:5180:1,10 184:22187:16 188:20

right-sided183:5rigorous152:1risk94:5 113:6,11,12

113:13,20 114:3114:6 123:18,19128:19 129:1172:4 185:20186:2,8,11188:12

risks94:4risk/benefit186:4Road3:5role10:10 49:22

104:13,17,18107:10 114:20161:15 184:5

Ron46:6room18:13 48:14

110:11rotate

174:9rotation24:20 27:7 28:21rough44:5round22:17,20 23:1rounding14:10 15:6 16:1

22:16 27:12routine70:14 185:10routinely70:12 89:1,3rule80:13 81:22

133:2 153:2RV96:2 101:7

S

S1:17,22 2:1,5,13

3:1 4:1 5:1,2,76:1,2 196:2197:16

saddle78:17 80:2 82:14

82:15 137:17,19137:20 172:6,12

Saint1:12 3:11 32:1

34:2 51:10 52:656:16 73:1678:12 82:7 96:9103:20 110:12127:20 138:22152:2

saliva188:8salvageable121:8 122:8,20

123:15Sanders45:11,13saturation27:22 77:12,19

189:11,15

save92:16 140:4

158:1saved123:16saw39:14 135:21saying35:10 40:16

65:19 79:1 98:598:9 132:16141:3 160:4169:8 178:16

says59:16 66:12 68:8

73:20 74:1,4,474:11,16 83:18

scan80:12 81:6,12,21

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T

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197:1,1tabbed33:20 34:8,8tabs33:21 34:17tachycardia27:22 55:14 63:1

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70:19 71:2,3119:18 144:19151:22

transcript5:8 33:6,8 57:2

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transcription196:5

transcripts37:13 46:11 47:6

73:14 155:6transfer18:15 19:4transferred97:5transfused104:7,8transfusions105:17transient188:9trauma108:18treat85:22 89:7

106:11,17treatable97:3treated94:14 112:3

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