Ch. 1 – Full cross examination defendant physician Timothy Madison

CROSS-EXAMINATION OF PHYSICIAN DEFENDANT TIMOTHY MADISON BY PLAINTIFF ATTORNEY MR. AUGUST:

Q. State your full name, please.

A. Timothy Madison.

Q. You are a physician?

A. I am.

Q. You are a defendant in this case?

A. I am.

Q. You are employed by Emergency Services, Incorporated?

A. Emergency Specialists, Incorporated.

Q. Okay. Is that a corporation that – my recollection from our having had sworn testimony before is that you were employed by Emergency Services, Incorporated. Is that an error?

A. Yes. It’s — Emergency  Specialists is the title of our corporate — or our corporation.

Q. Okay. And you’re an owner of that corporation?

A. I’m a partner in that corporation.

Q. Well, partner meaning you have an ownership interest in the corporation, right?

A. That’s Correct.

Q. Okay. And were you working in the course and scope of your employment when you were in the emergency room on November 6, 2002, taking care of Mrs. Kamianka?

A. Yes, I was.

Q. Okay, And is Dr. George Smith (named changed as are others below) one of your partners?

A. Yes, he is.

Q. And I believe that your group covered the No Name Hospital emergency room, correct?

A. That’s correct.

Q. And just to orient the jury, Dr. Smith is the person who dictated and signed the note for the time at the end of the day on November 6, 2002, when Mrs. Kamianka was brought in dead on arrival, right?

A. Yes. That’s correct.

Q. So your partner filled out that note at the end of the day and the dictation, correct?

A. Yes. That’s correct.

Q. Now, you have been at No Name since 1997?

A. That’s right.

Q. Are you still working in emergency medicine?

A. I am.

Q. And are you still working at No Name?

A. Yes, I am.

Q. By the way, is No Name a part of the   Clinic Health System?

A. Yes, it is.

Q. And it was in 2002?

A. Yes, I believe it was.

Q. And No Name didn’t have the capability to do catheterizations, did it?

A. That’s correct.

Q. So, if you had to have a patient undergo a catheterization or bypass surgery or any other kind

of intervention that patient would be sent from No Name over to the Clinic main campus; is that right?

A. They can be sent either to Clinic, or the other option that we have is Hilltop Hospital.

Q. Okay. But both clinic facilities that would have the capabilities of doing those kinds of things, right?

A. That’s correct.

Q. Now, would you agree with me that potential cardiac symptoms include back pain, chest pain, vomiting and arm pain?

A. They are potential symptoms, that’s correct.

Q. Now, when you are interested in trying to determine or diagnose whether a patient has myocardial ischemia, what kind of things do you do?

A. Initially I would talk to the patient, try and elicit a history. I would look at notes or vital signs that the nursing staff had taken. And, then, I would examine the patient to try to get some further information about what’s going on with the patient.

Q. Okay. And you stop there and the examination?

A. No. After the examination and their history is taken, then I would make a determination as to

whether further testing needed to be done and whether further treatment at that point was indicated.

Q. Okay. Well, I was talking about a patient where you suspected cardiac ischemia, okay?

A. Yes.

Q. Okay. So, would it be true that after the history and after the physical in a patient with potential cardiac  ischemia you would do an EKG?

A. That is a possibility.

Q. And you would probably order blood work to determine whether or not there was something that may

have occurred in the form of a heart attack, right?

A. That’s a possibility, also.

Q. Because enzymes will show that, right?

A. Well, enzymes are a part. They won’t necessarily show it all of the time.

Q. I understand that. I understand that. But if it’s a more recent bit of damage to the heart, the

cardiac enzymes will show up as abnormal on the blood work, right?

A. They can, yes.

Q. And, likewise, an EKG is going to show if the patient has an abnormality from past damage that left

some scar in the heart or acute ischemia at the time of the EKG, right?

A. That’s a possibility. It is not 100 percent.

Q. And I’m not suggesting that it’s always 100 percent. Part of what you do when you’re talking to the patient and getting this history is to also assess risk factors to whatever extent you can, right?

A. In relation to a patient that’s presenting with cardiac symptoms, is that your question?

Q. Right, yes.

A. Yes, that’s correct.

Q. Okay. Now, you had indicated before that patients that may need a cath or treatment intervention, for example, with a cardiac problem, would be sent to the   Clinic main campus or over to Hilltop. Was there a time when they used to be sent over to St. Angel as well?

A. I don’t recall that in my experience at No Name. I can’t say for sure about that.

Q. You can’t recall ever having a patient that you know of from No Name that was sent over to St. Angel?

A. Not off the top of my head, no.

Q. Now, on the day in question, November 6th, 2002, you worked from 9 p.m. the night before  until 7 a.m. on the morning of November 6th, right?

A. That’s correct.

Q. And I believe, based on the records that we looked at in this case the emergency room has about 17 beds or rooms, correct?

A. That’s correct.

Q. And, again, I’m talking about 2002, just to orient you in the event there has

been any changes.

A. Yes.

Q. And at the time when Mrs. Kamianka was in the emergency room at about 4:45 to 6:35 in the morning, the maximum number of beds in use or rooms in use was eight, right?

A. I’m sorry, can you rephrase the question? I’m not sure I understand it.

Q. There were about eight patients in the ER when Mrs. Kamianka was there, right?

A. I don’t recall exactly, but that — that may be right.

Q. Well, I’m going to hand you what’s been marked as Exhibit 3 which I have been told is the emergency

room log or emergency department log for this day at No Name, and you’ll see that Mrs. Kamianka is

listed as one of the patients that morning, correct?

A. That is correct.

Q. And it shows the date and the time as well as her account number, how she got there, her sex, her

age, her complaint, medical record number, and the discharge time, right?

A. That’s correct.

Q. And the entry date — I guess the time of arrival is 4:44 according to this and the discharge is 6:35, right?

A. That’s correct.

Q. And pain in the chest is one of the complaints that’s listed in the log, correct?

A. It’s one of the complaints. There are multiple complaints.

Q. Okay. Pain in the arms, pain in the back, pain in the chest and vomiting, right?

A. That’s correct.

Q. I assume the complaint would be what amounts to the chief complaint of the patient for the visit, right?

A. That’s right.

Q. Now, if you look down this list particularly as it relates to the times, would you agree with me that there are eight patients who were in the ER including Mrs. Kamianka at the time when she was

being treated?

A. That may not necessarily be true. This is the log which begins at midnight and goes on throughout the day. There are eight patients listed up to that time. So, there had been eight patients checked into the

emergency room after midnight. I can’t say for sure whether some of those patients had been discharged or whether they were still in the department.

Q. Okay. So the maximum number of patients that would have been there when Mrs. Kamianka was is eight and it could have been less?

A. Yes, that’s right.

Q. So it could be that there were only three, four, or five patients in the ER at the time when she was being treated?

A. That is a possibility.

Q. All right. So this is by no means a real busy day or time for your work, right?

A. It’s probably an average day for that time of the morning.

Q. Now, when you were taking care of Mrs. Kamianka in the emergency room — I understand she

comes in and the nurse sees her and does a nursing assessment of the patient, right?

A. That’s correct.

Q. And this is done before you even see the patient, right?

A. Yes.

Q. And, then — and this nursing — just so the jury is oriented, this nursing assessment sheet is what’s been on the board and we have talked about here that lists at the very top chief complaint, back

pain, chest pain, vomit, arm pain, timed at 5:05, correct?

A. Yes.

Q. And then gives this history of the present illness about what brought her there in the first place, correct?

A. Yes.

Q. Now, this is prepared by the nurse before you ever see the patient, correct?

A. Yes.

Q. And it’s available for you before you see the patient to go in — before going in to see the patient, the material — or this sheet is there for you to review if you so choose, correct?

A. Yes, I will see that. I’ll pick it up, I may review it just before going in to see the patient  I may review it as I’m going in to see the patient.

Q. You also have the option of talking to the nurse directly and conversing a little bit about what this patient — what is going on with this patient and so on, correct?

A. Yes, I do.

Q. At no time as it relates to Mrs. Kamianka did you ever talk to Nurse Deitrick about her evaluation or assessment of this patient, correct?

A. I don’t believe that I did.

Q. So the only information you would have had available would be the documentary information from the chart which would include this nursing assessment sheet?

A. Yes

Q. Correct?

A. That’s right.

Q. Now, from your review of the nurse’s assessment sheet, which I assume you did look at before you saw her, correct?

A. Yes.

Q. Okay. From your review of this sheet, you were certainly aware that she had awakened from a sound sleep with back pain, chest pain, vomit and arm pain, right?

A. Yes.

Q. Doesn’t say anything in there, in that history about her having been awakened from a cough, does it?

A. No, it doesn’t.

Q. As a matter of fact, you don’t remember ever having gotten a history when you talked to Mrs. Kamianka directly about coughing being the cause of her being awakened, right?

A. I was able to obtain a history of the cough. I don’t have any documentation that it was the cough

that woke her up.

Q. Okay. What she did do when she woke up is she took Motrin, an over-the-counter painkiller, right?

A. That’s right.

Q. Now, Motrin is not the kind of medication that you would take for a cough as a layperson, is it?

A. No.

Q. Motrin is the kind of a pain — or a medication you would take for pain that you were experiencing; I mean, that’s typically what people use it for, right?

A. That’s correct.

Q. So, you would agree with me at least in the mind of Mrs. Kamianka that she had a severe pain that caused her to take Motrin and not a cough for which she would have taken something like a cough medicine, right?

A. No. I elicited a history that she did have a cough, but I would agree that she took the Motrin for the pain that she was having at that time.

Q. Now, when you saw this patient, you also took a history yourself, right?

A. That’s correct.

Q. And that history ultimately was dictated by you, correct?

A. Yes.

Q. The very first thing you show is the chief complaint for Mrs. Kamianka that morning was chest pain, correct?

A. Yes. I also included the other two complaints that she had initially which were coughing and vomiting.

Q. I understand that. The fact is the very first thing you listed in this case as a complaint of this patient was chest pain, right?

A. The order of those complaints is not significant. She had all three complaints as her initial assessment.

Q. Okay. Well, ,you would agree with me that chest pain is often associated with a cardiac problem, isn’t it?

A. It is a possibility.

Q. Now, you never even asked her about the intensity of her chest pain, did you?

A. I did not ask her that specifically. The intensity of the chest pain was documented on the nurse’s notes.

Q. And that’s the thing that shows that she had an intensity that was eight out of ten, correct?

A. That’s right.

Q. Now, eight out of ten is a very severe degree or level of pain, isn’t it?

A. Yes, it is.

Q. Have you — are you familiar with pain scales? I’m sure in medicine you have dealt with a lot of

different pain scales, right?

A. Yes.

Q. And are you familiar with the description that is typically given to describe an eight out of ten on a pain scale?

A. I’m not sure I understand the question about description.

Q. Well, obviously, the more — the higher the number the more severe your pain?

A. That’s right.

Q. So if somebody has got a two, it’s a lesser degree of pain; if somebody has got an eight or a nine or a ten, it’s a more severe degree of pain, right?

A. That’s right.

Q. So, there are characterizations that are given for pain scales so that people know whether they fall into the five, the six, the three, the eight, kind of scale, correct?

A. Yes.

Q. Would you agree that an eight would have – is characterized — or can be characterized as physical activity severely limited; you can read and converse with effort; nausea and dizziness set in as factors of pain on occasion?

A. It sounds to me like you’re reading that from a text. Could I-

Q. I’m reading this from a pain scale called Mankoski Pain Scale, okay, just pulled off the internet. Do you have any reason to disagree with that pain scale description for an eight out of ten?

A. No, I don’t.

Q. Now, you never even asked Mrs. Kamianka about — you didn’t ask about the intensity. You also didn’t ask about the duration of the pain, correct?

A. That’s correct.

Q. It would be something that would be important to know, isn’t it?

A. Depending on the presentation of the patient, yes.

Q. And that’s something which is helpful to make a diagnosis, isn’t it?

A. It can be.

Q. And would you agree that if a patient has chest pain for more than five minutes that they

should go to an ER for evaluation and assessment?

A. That is not necessarily true. It would depend on what other symptoms the patient is experiencing

and what the context of the chest pain is.

Q. You never asked Mrs. Kamianka about the intensity or the duration and the fact is you cannot remember why you didn’t ask her more detail about her chest pain, do you?

A. I’m not sure I understand that question.

Q. Well, do you know why at this — as you sit here and after you have evaluated this case in your mind for years, why you didn’t ask her more detail about her chest pain? You don’t remember that, do you?

A. Well, the presentation of the patient was fairly straightforward when I asked her the questions in the history.

Q. Do you know if Mrs. Kamianka ever had chest pain in the past? I don’t mean now. I mean when you were seeing her. Did you know on November 6th, 2002, after talking with Mrs. Kamianka at the end of that visit whether she had ever had chest pain in the past?

A. I don’t know. Or I didn’t know at that time.

Q. Right. You know now, obviously.

A. Yes.

Q. But at that time you didn’t know, right?

A. Right.

Q. And that’s because you didn’t ask her, right?

A. That’s correct.

Q. You also didn’t ask her about any family history of heart disease, did you?

A. That’s right. And the reason that I didn’t was–

Q. I didn’t ask that, sir. You can give that later. The fact of the matter is you didn’t ask about prior chest pain; you didn’t ask about family history; and you didn’t know anything about her brother being 32 at the age of his MI and death, right?

A. At that time, no.

Q. Okay. That sort of information in a patient who presents with chest pain as a complaint would be important to know, wouldn’t it?

A. It would be important depending upon the history and physical exam that was taken initially and on the context of the presentation of the patient.

Q. Now, the other thing that this history tells us when she says she’s awakened from a sound sleep with the symptoms including chest pain is that that chest pain by definition is unstable angina, right?

A. No. That is not necessarily true.

Q. Okay. Is there, in fact, a definition of unstable angina that means you get chest pain at rest or without exertion?

A. That is a definition of unstable angina.

Q. And unstable angina, at least as defined in that context, is dangerous, is it not?

A. Yes, it can be.

Q. . Because it can lead to an MI or a heart attack, can’t it?

A. Yes, it can.

Q. And now as we sit here we know that indeed occurred, correct?

A. No, I don’t think that can be said. I mean, eventually the demise of the patient was due to an MI; we can say that.

Q. Well, again, I think what you’re trying to tell the jury is that this woman had absolutely no cardiac problem at all when she was in the emergency room on the morning of the November 6th, right?

A. No. I’m not saying that at all.

Q. Okay. So would you admit that on the morning of November 6, 2002, when she was in the emergency room with a chest complaint that she had a cardiac problem?

A. She — from the — in hindsight from the pathology report we understand that she did have cardiac disease. I’m not denying that.

Q. Okay, You’re not suggesting that she was without any cardiac problem at the time of the emergency room visit but sometime in the next 12 hours there was some migration of a clot to her left anterior descending, are you?

A. No, I’m not.

Q. Now, one of the things you ordered for her was Tylenol, right?

A. Yes.

Q. And that, I guess, would be for pain, right?

A. That’s correct.

Q. You also ordered a chest x-ray, correct?

A. Yes.

Q. And you — when she ultimately went to get the chest x-ray in the radiology department, she actually was made to walk there, right?

A. Yes. She did walk to the radiology department to get the chest x-ray done.

Q. Would it be your practice to send somebody with chest pain and a potential cardiac problem to another department in the hospital, have them walk there as opposed to going by wheelchair?

A. Not if they came in with a clear-cut cardiac problem. This patient presented with cough, post tussive vomiting. The cough was productive. She coughed so hard she was vomiting. That is not a presentation of a patient who has cardiac ischemia. Therefore, both my assessment and the assessment the nurse on this presentation was such that the

patient was able to walk to the radiology department to get her chest x-ray.

Q. Well, were you relying on the nurse’s assessment?

A. I take that into consideration.

Q. Well, okay, we will get to that. You say if there are clear-cut cardiac problems or symptoms you wouldn’t have them walk; you would have them go by wheelchair; is that what you said?

A. What I’m saying is if a patient comes in with heavy chest pain complaining that this is a terrible pain that they have in their chest; they can’t breathe; it gets worse when they exert themselves; that is a patient that I would not send to the radiology department. I would get a portable chest  x-ray•

Q. Well she had severe pain in her chest as well as her back that was rated eight out of ten, right?

A. And if you read in the nurse’s notes it says in the second line that most of that pain was between the shoulder blades and radiating down the right arm.

Q. Right. Where is your heart?

A. It’s in the — it’s actually a little left of the center of the chest.

Q. A little left of center in the chest, but it’s —

A. Yes.

Q. — between your chest and your back, right?

A. That’s correct.

Q. It’s not out in the front with nothing in the  back, right?

A. That’s correct.

Q. So, it lines up pretty much between the shoulder blades as to where it’s physically located, correct?

A. That’s right.

Q. And the severe pain that she has between her shoulder blades, based on all the history she gave you, there was nothing to say that that could not have been the heart that was exhibiting the pain in her system, correct?

A. But if you will —

Q. Correct? Correct?

A. That is–

Q. Correct?

A. That is a possibility.

Q. Okay.

A. Can I answer further?

Q. You’ll have your opportunity to explain your side. I’m just trying to get something through here. You have — in addition to that eight out of ten, you have chest midsternal pressure — pressure. Now, would you agree with me that pressure or tightness in the chest can be a sign of a cardiac problem?

A. It is a possibility. It can also be a sign of multiple other problems that are going on including respiratory type problems.

Q. Right. And — so, respiratory; it could be bronchitis?

A. Yes.

Q. Could be perhaps pneumonia?

A. Yes.

Q. Could it be a PE?

A. Yes

Q. And it could be a heart problem?

A. That’s in the line of possibilities.

Q. Now, somebody could have a heart problem that could be fatal, right?

A. Yes.

Q. What’s it take to order an EKG?

A. I would have to circle the order and give it to the secretary to get ordered.

Q. Okay. And the secretary gives it to the nurse, and the nurse puts the 12 leads on the patient, plugs them in and runs off the strips to determine what the EKG is showing for that patient’s heart, right?

A. That’s correct.

Q. And this is a fairly — this is a – totally risk free to the patient, isn’t it?

A. Yes.

Q. And it is inexpensive, correct?

A. I don’t know the cost.

Q. Okay. Cost certainly should not be a factor that you would take into account, right?

A. Right.

Q. Okay. And it is reliable in the sense that it can give you information, more information about the status of that person’s heart and heart rhythm, right?

A. That’s correct.

Q. And it doesn’t take very long to do, does it?

A. No.

Q. And it’s all right there in the ER. I mean, they can do it with no difficulty at all in the ER. It’s not like you got to go across the street or I didn’t ask about certain risk factors around the corner. Right?

A. That’s right.

Q. Isn’t it true, Doctor, that you never even considered ordering an EKG on Mrs. Kamianka?

A. I did not consider ordering an EKG because was not indicated in this presentation.

Q. Well, you keep talking about presentation, and I’d like to ask you about that. Isn’t the patient’s presentation based in part on your observations and the information you gather?

A. Yes, it is.

Q. As a matter of fact, that’s a large part of the presentation, as you call it, right?

A. Yes.

Q. So, if you don’t know anything about certain risk factors or history in that patient – for example, the risk factors she had for coronary artery disease — that’s because you didn’t ask about it, right?

A. I didn’t ask about certain risk factors because of the complaints, the history and physical and the nurse’s notes that were obtained in the department that morning.

Q. In other words, because she came in complaining of chest pain you decided not to ask her about a history of CAD or heart disease or chest pain?

A. She was not only complaining of chest pain, but if you take the entire context of her complaints, it was not a cardiac presentation.

Q. My point being, Doctor, that presentation is dependent on you and what you do or say to a great

extent, right?

A. To a great extent.

Q. And you can’t necessarily rely on a patient to offer information about her history or her prior episodes of chest pain or her prior family history, you can’t rely on a patient because the patient doesn’t know what is important for you to evaluate, correct?

A. That’s correct.

Q. That’s why it’s up to you to gather the information and ask the questions to get this stuff so you can put it in the context of what’s going on with that patient, right?

A. Yes. And those questions that are asked are guided by the examination and the interview or the history obtained from the patient.

Q. And it’s your testimony in this case that that presentation, as you call it, didn’t fit the diagnosis of something that could be cardiac in nature, right?

A. That is right.

Q. Well, what does the term rule out mean in medicine?

A. Rule out means that you consider something and then do further testing to say that that diagnosis or that disease is not present.

Q. Okay. So, it’s a — it’s — it’s an evaluation and testing to exclude a particular thing as the source of the problem?

A. That’s right.

Q. Okay. For example, if somebody has a biopsy and it comes back negative, they don’t have cancer; I mean, it’s a way of saying, okay, we have tested, and we found that there’s no cancer in this patient or in their liver or whatever it may be, right?

A. Yes.

Q. And for heart problems, the cardiac catheterization seems to be, I think you would agree the gold standard for the testing and evaluation of whether somebody has coronary artery disease, correct?

A. Yes.

Q. So that would be an example of a test that rules in or rules out cardiac — coronary artery disease in a patient, right?

A. Yes, it is.

Q. But in your practice, you certainly don’t order the cardiac catheterization as the first line of testing for a cardiac problem, do you?

A. No, I would not.

Q. The fact of the matter is the first thing you would do is get an EKG, right?

A. If it was indicated, according to the patient’s presentation, then, I would, yes.

Q. And then you would follow that or at the same time get blood studies done to evaluate whether or not there is any evidence of a cardiac enzyme elevation, right?

A. Yes.

Q. Now, are you capable of interpreting an EKG?

A. Yes, I am.

Q. And I’m sure that you have probably ordered thousands of EKGs in the emergency room in your career, right?

A. Yes.

Q. And an EKG is certainly a test that can help to rule in or rule out a potential cardiac problem, right?

A. Yes, it is.

Q. And if a patient has past damage to their heart, some damage in the form of a scar or necrotic tissue from some other event previously, an EKG can show that abnormality, right?

A. It can. It does not always.

Q. I understand. Depends pretty much on how significant that is, right?

A. Yes, that’s right.

Q. And whether it interrupts or affects the conductivity of the heart electrically on the EKG, right?

A. Yes.

Q. Likewise, if somebody has ischemia, acute ischemia, they come in, and they have got chest pain, they have got chest pressure, and they have got what amounts to closing or narrowing of the arteries, the coronary arteries, that’s going to show up in an EKG, isn’t it?

A. Not all the time, but it can.

Q. But it certainly can?

A. Yes.

Q. And if it does, it gives you another piece of the puzzle to say we better look further on that, correct?

A. Yes.

Q. And if that EKG came back in a positive or abnormal fashion, regardless of the enzymes, you may go to yet another test, like a stress test, correct?

A. Are you saying I would go to a stress test if there were abnormalities on the EKG, is that the question?

Q. If there are abnormalities in the preliminary testing for EKG and enzymes, one or the other, particularly the EKG, it may result in going to the next level which would be a stress test?

A. It may.

Q. All right. And it may lead to a cardiac catheterization, which would be diagnostic of CAD, right?

A. That’s correct.

Q. Now, would you agree as a general proposition that people who experience chest pain for any period of time should, in fact, get it evaluated; that’s a good piece of medical advice to the general public?

A. Yes, it is.

Q. Why is it important for a person with chest pain to go to the hospital?

A. To have that chest pain evaluated.

Q. Is it also to determine what that physical condition is that’s causing the chest pain?

A. That would be part of the evaluation.

Q. Is it also because chest pain can be a sign of something that is more serious that could occur?

A. It depends on the context of what’s going on

at that time, but it can be an indicator of something more serious going on.

Q. And it’s also because chest pain and whatever it represents can be successfully treated, right?

A. Yes, it can.

Q. And if it is chest pain caused by ischemia, for example, that would be a harbinger or something that would perhaps be more serious later on like an MI, right?

A. That’s correct.

Q. And if it’s caused — if the chest pain is caused by ischemia, would you agree that it can be successfully treated and an MI or heart attack can in many instances be avoided altogether?

A. Yes, that’s right.

Q. Now, as I understand it, No Name Hospital has a chest pain protocol; is that right?

A. I believe you’re referring to a nursing protocol if I’m correct.

Q. Well, but No Name Hospital for the emergency room nurses gives them a protocol saying if somebody comes in with a chief complaint of chest pain this is what you should do?

A. They have multiple protocols for different presentations. Chest pain would be one of those.

Q. Okay. And all I’m talking about right now is chest pain, not appendicitis or anything else. And is Exhibit 26 a complete copy of the guidelines of care for — or protocol for chest pain?

A. Yes, it is.

Q. And you say this applies to nurses because they need to have this to guide them through their work; is that right?

A. I’m not sure you can say they need to have this. This is present so that if they have a patient presenting with this  complaint, then they will have guideline that they can use to guide their workup that patient in the emergency department.

Q. Right. And would it be fair to say that from your perspective anyway you don’t think this applies to physicians?

A. No. This applies to the nursing staff.

Q. And I assume that it applies to nurses because they are not as well trained as doctors so they may need a little bit of guidance to deal with the potential risk associated with a complaint of chest pain, right?

A. Well, I wouldn’t say that the nurses are less trained. I would say they are trained in a different venue. So, these guidelines are to help them in the workup of that patient.

Q. But isn’t it true, Doctor, that if appropriate you even follow these guidelines?

A. I’m not sure I understand the question. Are you saying that I should –I’m bound by these guidelines?

Q. No, I didn’t say that. I said, isn’t it true that you, in fact, follow these guidelines if appropriate under the circumstances?

A. I don’t follow nursing guidelines.

Q. I’m sorry?

A. I don’t follow — I don’t use nursing guidelines in my workup of patients.

Q. Well, I’m going to draw your attention to page 23 of your deposition at line 12. It says,  guidelines — I’m sorry, line 11: That you are to follow those guidelines? That was the question. Answer: Guidelines are guidelines. They’re

used as a reference. So if you — if you are saying, well they’re binding and you have to follow them,  that’s not correct.

Question: But it is suggested by the   Clinic Health System that you consult those and follow them if appropriate; is that right?

Answer: If appropriate, that’s correct. That’s what you testified to under oath in this case, did you not?

A. In that deposition at that time, you were referring to physician guidelines from the   Clinic. I don’t believe that you were referring to the nursing guidelines that we’re talking about at No Name.

Q. I’m sorry to differ. One of the things you also do in your work that you —

MR. SMITH: Objection, Your Honor, the — objection.

THE COURT: Sustained.

BY MR. AUGUST:

Q. One of the things you also do is give courses every once in awhile to emergency medical technicians; is that right?

A. I don’t give courses. I do continuing medical education for paramedics.

Q. All right. I’m sorry I called them courses. You give talks that are substantive for the benefit of emergency medical technicians, correct?

A. That’s correct.

Q. And I assume that you talk to them about a variety of subjects, correct?

A. Yes.

Q. And I assume you also tell them about how to deal with a patient that has chest pain complaints, right?

A. Yes,

Q. And I assume you also are aware of the fact that emergency medical technicians do EKGs on these patients even in their homes or in the truck or on the way to the hospital, correct?

A. Yes.

Q. Do you tell emergency medical technicians if there’s chest pain you don’t always have to do an EKG?

A. No, I don’t tell them that.

Q. Okay. The fact of the matter is you teach them that if there’s a chest pain complaint get an EKG as a matter of course, correct?

A. No. They — paramedics do not always get an EKG. They do have monitors on the trucks, and they will typically place the patient on monitors, However, emergency medical technicians and paramedics are guided by a set of guidelines according to their training.

Q. Their guidelines are different than physicians?

A. And nurses.

 Q. Okay. Now, when Mrs. Kamianka checked in, her chief complaints, as we said, was back pain, chest pain, vomiting and arm pain; and I believe you indicated that you got a history of cough and post tussive vomiting; is that right?

A. That is correct.

Q. Now, was the coughing the reason why you elected not to get an EKG on Mrs. Kamianka for her chest pain complaint?

A. Coughing was part of that, in my judgment, but I took in context all of the complaints and all of the history that Mrs. Kamianka was giving me at that time; and as a result of that, I, I did not elect to get an EKG at that time.

Q. What about a cough rules out a cardiac problem in a patient?

A. Cough in itself does not rule out a cardiac problem.

Q. As a matter of fact, Doctor, you’re not suggesting to this jury that a person who has a cough can’t have a heart attack or can’t have heart disease, are you?

A. No, I’m not,

Q. Well, was another one  of these various reasons the fact that there was yellow sputum that she apparently had coughed up, was that another part?

A. That is another part in the history that the patient gave to me.

Q. Is yellow sputum something that rules out or excludes a cardiac cause for the complaints of chest pain?

A. No, it does not.

Q. A person who has a cough and productive yellow sputum certainly can still have a heart attack or  heart disease, right?

A. That is a possibility.

Q. Was it the pain that was between her shoulder blades that led you to believe that this complaint didn’t need or require an EKG?

A. Pain between the shoulder blades is an atypical type of presentation for cardiac ischemia or coronary artery disease, but that in itself did not lead me away from getting an EKG.

Q. Well, but pain between the shoulder blades certainly doesn’t rule out a heart problem, does it?

A. No, it doesn’t.

Q. And a person can have an MI or heart disease and still have pain between the shoulder blades, right?

A. Yes, they can.

Q. As a matter of fact, you talk about it as an atypical presentation for heart disease; is that what you said in so many words?

A. That’s exactly what I said.

Q. Well, you are aware of the fact that women more often present with atypical or different kinds of presentations than men, right?

A. Yes, women can.

Q. Was it the cervical spine scoliosis on x-ray that caused you to think that this was not cardiac in origin?

A. No. It was part of the entire workup, history and physical exam that I did. That was part of it, but that in itself did not eliminate me from getting an EKG.

Q. And I didn’t say in itself. This is one of a list of things that you believe pointed you in a direction other than her heart?

A. But what you’re doing is taking each one specifically and singling it out; and I’m saying that I took all of those in context as an entire presentation of the patient and as such did not order an EKG.

Q. Well, wouldn’t it be fair to say that for all of those things that we have just listed, put them altogether, that a patient who has all of those things still can have a heart attack?

A. That’s a possibility. All things are possible.

Q. And they still can have heart disease?

A. Yes, they can.

Q. And the chest pain they present with can be perfectly consistent with heart disease or heart attack?

A. Are you referring specifically to Mrs. Kamianka?

Q. I’m talking about a patient who comes in with those things that you said pointed away from cardiac despite the presence of chest pain.

A. She had chest pressure. Most of her pain was between the back and down the right arm.

Q. Which as you acknowledged earlier can be from the heart, right?

A. It’s a possibility.

Q. None of the things that you found  as  factors leading you away from chest pain would rule out cardiac as a cause, would they?

A. That’s correct.

Q. And anyone of these or all of these things could be in a person who still has heart disease or is going through a heart attack, right?

A. Yes, it can.

Q. So what about Mrs. Kamianka’s presentation makes it okay not to do an EKG?

A. Well, you’re saying that with this presentation that I’m obligated to rule out a cardiac origin. I’m saying that that is  not the case. The patient presented with these symptoms, and I’m saying that there’s no evidence in those symptoms that the patient had ischemic cardiac disease. The presentation was one of bronchitis and an infectious upper  respiratory disease; and as such, I’m not obligated to rule out a cardiac origin.

Q. Well, let’s just see. The log sheet that you have up there shows as one of her complaints chest pain, correct?

A. That’s correct.

Q. And the No Name Hospital patient information sheet shows chest pain as one of her chief complaints, correct?

A. That’s correct.

Q. And your listing as the first chief complaint or one of the chief complaints is chest pain, correct?

A. That’s correct.

Q. And the nurse noted from the assessment chest pain as one of the chief complaints, right?

A. Yes.

Q. And described chest pressure and pain in the history, correct?

A. Yes. Can I make a clarification?

Q. And then there is further an order for the chest x-ray and the clinical history given for that is chest pain, correct?

A. Yes. Can I make a clarification about that,

Mr. August?

Q. About which?

A. About the multiple areas of chest pain that you’re talking about.

Q. Sure.

A. The — let’s just take the last one for instance. The order for the chest x-ray as indicated as chest pain that is put in by a clerk in the  emergency department who’s taking the information off  of the nurse’s notes. The log is entered by a registrar who is in the front of the emergency department and is again taking that information off of the nurse’s note. So, most of this is coming from one source which would be the nurse’s notes or my chart. It’s not significant that each of those different individuals are getting a history of chest pain from the patient. That is not the case.

Q. And I never said that, Doctor. The fact of the matter is it’s coming from the medical people who have taken the history and recorded the chief complaints, that’s you and Nurse Deitrick?

A. That’s correct.

Q. And two of the references we identified here are from your record and Nurse Deitrick’s record and say the chief complaint includes chest pain, right?

A. Yes. And you’re taking that totally out of context as chest pain itself.

Q. All right. Up there in signs and symptoms, what does it say for Mrs. Kamianka?

A. Where are you pointing to, sir?

Q. Signs and symptoms. What does it say here for signs and symptoms relating to Mrs. Kamianka?

A. Pain in chest. And, again, that —

Q. Thank you.

A. — is entered by the clerk who puts the order for the chest x-ray in, yeah.

Q. Now; if all of these things that we have talked about caused you to conclude that an EKG really didn’t have to be done on her, tell me this: What does a patient need to have at a minimum to get an EKG when they come in with chest pain if you’re the one covering the ER?

A. Well, the patient certainly wouldn’t present with a productive cough, that she coughs so hard she would be throwing up and causing the chest pain. That is not the presentation that would lead me to get an EKG.

Q. Can a patient who comes in with a productive cough that’s coughing hard, coughing enough to vomit, can that patient still have a heart attack?

A. All things are possible.

Q. Can they still have heart attack or heart disease when their complaints include chest pain?

A. Yes, they can.

Q. And that’s pretty important to rule out if you have a means of doing it so easily accessible to you in the emergency room, isn’t it? Isn’t it?

A. To order that test, you need to have an indication as to why that test needs to be ordered and that was not present in this case.

Q. Truth is, Doctor, you never even thought or considered a cardiac cause for Mrs. Kamianka’s chest pain complaints, did you?

A. It was in the differential when I initially evaluated the patient; but as I got further history and physical exam, it went further and further down the list, and I did not work that part of the differential up.

Q. Isn’t that failure to even consider it the reason you don’t even remember if she was on a heart monitor in the emergency room that morning?

A. I’m not sure I understand that question.

Q. Well, haven’t you already testified in this case that you don’t even remember if she was on a heart monitor that morning?

A. That’s correct. I don’t recall that.

Q. And isn’t the reason you don’t remember she was even on the heart monitor that morning is because it wasn’t even in your thought process that she could have a cardiac problem at the core or the root of her chest pain complaints? Isn’t that the reason why you don’t even remember if she was on a heart monitor?

A. No. That has nothing to do with it.

Q. And isn’t it also the case that you don’t ever remember ever looking at any heart monitoring strips or heart monitor information about Mrs. Kamianka’s heart rate, heart rhythm, things that would show up on a heart monitor?

A. That’s correct. I testified to that previously.

Q. In fact, Doctor, isn’t it true that once Mrs. Kamianka mentioned the fact that she had been to her family doctor and had a diagnosis of bronchitis some weeks before that you presumed the same diagnosis and operated accordingly? Isn’t that true?

A. No, absolutely not. I based my treatment upon my interview with the patient, upon the history that obtained, upon my physical exam and the treatment of the patient in the emergency department. I did not base my — I do not base my treatments and evaluations upon another physician.

Q. Doctor, you learned about Mrs. Kamianka’s death not long after it happened, right?

A. That’s correct.

Q. In fact, you got a call at home from the ER — or ED director, correct?

A. Yes, that’s right.

Q. And that call concerned you quite a bit, didn’t it?

A. Yes, it did.

Q. And isn’t that why you requested a copy of the

autopsy from the coroner’s office only days later, on

November 20th?

A. Yes, I did.

Q. And in that letter didn’t you indicate to the coroner that this was your patient?

A. Yes, in the emergency department.

Q. And you have reviewed the autopsy since then, haven’t you?

A. Yes, I have.

Q. You don’t have any reason to disagree with the coroner about what her cause of death was, do you?

A. No, I don’t.

Q. And you have looked at that autopsy?

A. Yes, I have some time ago.

Q. And you are familiar both from your review as well as the other testimony in this case that Mrs. Kamianka was not found to have any bronchitis on autopsy, right?

A. I don’t know that that was specifically looked for in the autopsy. I may be incorrect about that.

Q. Do you have anything to tell this jury that says that there was evidence of bronchitis in Mrs. Kamianka on autopsy?

A. No, I don’t.

Q. So, there is no reported pathological basis to say Mrs. Kamianka had bronchitis on autopsy, right?

A. That’s correct, but they may not have investigated that during the autopsy.

Q. As of November 2002, Doctor, is it true and did you agree that cardiovascular disease was the number one killer of women in the United States?

A. Yes, I believe that it was.

MR. AUGUST: Thank you very much.

THE COURT: Thank you Mr. August.

Doctor, you may step down.

Ladies and Gentlemen, we’re going to take our morning break. Break for about 25 minutes. During this time you can go downstairs, get a cup of coffee if you’d like. Please don’t discuss the case among yourselves or with anyone else. Don’t form or express any opinions until you hear all the evidence.

All rise for the jury.

(Thereupon, a recess was had.)

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