Ch. 6 – Plaintiff cross examination of defendant Timothy Madison

WHEREUPON, called to appear as a witness in this proceeding was one:

D O C T O R   TIMOTHY MADISON who, having been duly sworn by the bailiff herein, testified as follows:

THE COURT:   Mr. Morgan?

MR. MORGAN:   Thank you, Judge.

AS UPON CROSS EXAMINATION

BY MR. MORGAN:

Q             Could you state your name, please?

A             Timothy Madison.

Q             Doctor Madison, you were responsible for the care and treatment of Kelli Flood when she came to the ED on August 8th, 1999?

A             That’s correct.

Q             When she came to that emergency facility you were employed by the defendant, The Best Health Care Services, Inc.?

A             That’s correct.

Q             And you are still employed there?

A             Correct.

Q             And that’s a professional corporation; is it not?

A             That’s my understanding; yes.

Q             And you’re a partner in that professional corporation?

A             That’s correct as well.

Q             In The Best Health Care Services, Inc. there are approximately two hundred doctors, two hundred partners in that —

A             As of the last count I heard.

Q             Roughly?

A             Certainly.

Q             All right.  They’re in multiple states?  I think five is what you had said.

A             I’d have to sit back and re-think it at this point, but it sounds about right.

Q             All right.  Since 1990 have you been with The Best?

A             Actually a company it absorbed from 1989.

Q             Okay.  Doctor Snyder, one of the doctors that is defending you, you and he are partners?

A             Not at this time.  Let me backtrack.  Doctor Snyder and some of the other doctors at one contract decided to leave The Best.  I believe it was about two years ago, but it may have been three.  I believe he is no longer a partner or shareholder in the company, but I don’t know that certainly.

Q             At one time you were?

A             That’s correct.

Q             And when Kelli Flood went to the emergency facility on August 8th you were?

A             To be honest with you, I don’t know.  I’d have to go back and look at the date that that change occurred, sir.

Q             If he says you were, you wouldn’t dispute that?

A             That’s correct.

 

Q             All right.  The Best Health Care Services, Inc. is a group of doctors that provide primarily emergency care for patients who need it?

A             That’s correct.

Q             All right.  And that facility is staffed with doctors, nurses, receptionist, and lab techs. twenty-four hours a day, seven days a week?

A             That’s correct.

Q             All right.  It’s the only emergency facility in the county?

A             That is correct unless something has changed of which I’m not aware.

Q             All right.  You’ve been a doctor for approximately seventeen to eighteen years?

A             I graduated from medical school in 1985; so, yes.

Q             Okay.  You’ve been involved in emergency practice since 1989?

A             Correct.

Q             All right.  You are not board-certified in emergency medicine, but you’ve been specializing in that for a long time?

A             That’s correct.

Q             All right.  I’d like to ask you some questions about how emergency doctors, of which you’re one of them, go about doing their job.  I have some general things.

 

A             Will I need to move, sir?

Q             No.  Can you see the chart?

A             You need to angle it, or slide it back.  That would be helpful.  Thank you.

Q             How’s that?

A             Better.

Q             All right.  I’ll try to write a little more clearer than I did at the beginning of the case.  I’m going to label this ‘duty of emergency doctors’.  Would you agree that your goal is to screen patients to find out which one of the patients, or, which of the patients has a disease or something that’s life-threatening or disabling, and which don’t?

A             That’s correct.

Q             All right.  Would you agree that your job is to diagnose and treat?

A             To diagnose and treat?  Of course.

Q             One of the ways you do that is by doing a differential diagnosis?

A             Correct.

Q             You do that on virtually every patient that comes in to see you?

A             Correct.

Q             There is a couple of different ways you do that.  One would be you take a history; right?

A             Correct, assuming the patient can offer it.  If not, you have to get information from bystanders or family members.  It depends on the situation.

Q             Sometimes people come in and they can’t talk, or they’re unconscious, or whatever; right?

A             Correct.

Q             The other way you do that is you do a physical examination?

A             Correct.

Q             And a third way would be different tests?

A             If you feel it’s indicated.

Q             Sure.  But, those are — I mean, those are the three general ways you would do a differential diagnosis to come to some type of conclusions in order to diagnose and treat?

A             As I noted, with the testing issues you have to assume, or, you have to feel that the patient requires a test.

Q             Sure.  You wouldn’t want to do an unnecessary test.

A             As a matter of fact, there’s a big push to cut back on that now nationally.

Q             All right.  When you do a differential diagnosis there’s a priority involved; isn’t there?

A             Which priority do you mean, sir?

Q             Well, I’m talking about life-threatening situations have a higher priority.  Would you agree with that?

A             Yes.

Q             All right.  Emergency doctors, nor any doctor, knows everything.  So, would you agree that part of your job as an emergency doctor is to know if you should consult with a specialist, or not?

 

A             I agree with that.

Q             Okay.

A             At least when I feel it’s indicated.

Q             Sure.  Part of that job is who to consult with; right?  Isn’t that part of your training to know who you should consult with?

A             Well, obviously you wouldn’t consult with a neurologist necessarily for a pediatric issue.

Q             Right.  So, you would agree with me?

A             Uh-huh; yes.

Q             All right.  Now, the goal is to identify those conditions that may have a very bad outcome so you can treat it; right?

A             Agree.

Q             Now, let’s go to that night.  Kelli came in to the emergency room at six thirty-two P.M.?

A             If you say it was six thirty-two.  This is a copy of the record from that night.  It does say six thirty-two.

Q             All right.  Do you know what day of the week that was?

A             No, I do not remember what day of the week it was.

Q             All right.  It was a Sunday.

A             Okay.

Q             All right?  Like most emergency visits, the nurse there took an initial assessment?

A             That’s correct.

 

Q             And she took vital signs?

A             That’s correct.

Q             One of the vital signs was blood pressure and that was above normal?

A             That’s correct.

Q             One fifty-six over ninety-five?

A             Let me look.

Q             Feel free to check if you need to.

A             Yea, one fifty-six over ninety-five.

Q             All right.  The other vitals – temperature, respirations, and pulse – those were not above normal?  Those were okay; weren’t they?

A             That’s correct.

Q             All right.

A             Well, respiration is a little high at eighteen.

Q             All right.  Nothing that alarmed you?

A             By itself; no.

Q             All right.  At six thirty-two she came in.  At six fifty-five you saw her?

A             Correct.

Q             All right.  You did an exam and a history, or a history and an exam?

A             Correct.

Q             I know that you didn’t time it, but your best estimate would be that that took approximately ten to fifteen minutes?

A             That’s typical.

Q             Okay.  You felt that she should have a CAT scan and so she went off to do a CAT scan; right?

A             Correct.

Q             And then you ordered, or, gave her some pain medication?

A             Correct.

Q             And some other things and at eight thirty-five, approximately two hours after she got there, you sent her home?

A             It says eight thirty-five.  Correct.

Q             All right.  Now, when she came in there you knew her blood pressure was high; right?

A             Correct.

Q             You knew that she had just delivered a baby eight days ago?

A             Correct.  She told me that.

Q             That was your very first sentence on your chart; wasn’t it?

A             Uh-huh; that’s correct.

Q             And you would agree that’s a major medical event in somebody’s life?

A             Delivering a baby?

Q             Yes.

A             I don’t know about major medical event, but certainly a happy event.

Q             Okay.  How about a major physiological event?

A             It depends on what your definition of major is.  Certainly there are changes that occur during the pregnancy and then those have to return to normal.

Q             Well, it was major enough that you put it in the first sentence; isn’t

 

that true?

A             Well, I thought it was important because if I chose to give her drugs for whatever reason, well, I wanted to be sure if she was breastfeeding.  I have a baby to worry about even if the baby’s been delivered.

Q             That was your only concern?

A             No.  I also had to think about things that might have been related to pregnancy as a cause for her presence in the emergency department.

Q             Again, back to that chart.

A             You mean under differential diagnosis?

Q             Correct.

A             Certainly.  Yes.

Q             All right.  You knew that she had a severe headache?

A             Correct.  That’s what she told me.

Q             All right.  The nurse had said that they asked on a scale of one to ten what is it.  Her response was what?

A             I’ll check and I’ll tell you. 

Q             Page two fifty-three at the very top.

A             Two fifty-three?  I’m sorry?  Which page are you talking about, sir?

Q             The page it’s stamped.

A             Okay. 

Q             At the very top.

A             A scale of ten.  I’m sorry.  Thank you.

Q             It was ten; right?

 

A             Ten out of ten; correct.

Q             Okay.  She also told you that it was the worst headache of her life?

A             Correct.

Q             You had asked in your history about whether she had got hit in the head or if there was some type of trauma and you found out —

A             I was told there was not.

Q             All right.  You knew that she had photophobia?

A             Correct.

Q             Nausea?

A             Correct.

Q             All right.  Signs and symptoms of pre-eclampsia/eclampsia.  The first thing involved is either you have a pregnant woman or recently delivered; would you agree with that?

A             To a point.  My training was that if it was after forty-eight hours post delivery that the likelihood of eclampsia and pre-eclampsia was essentially nil.

Q             I’ll get to that point in a little bit.  You’ll agree that it can happen with postpartum women?

A             That’s correct.

Q             The hallmark, you know, is high blood pressure.  That’s an essential element of that diagnosis.  Do you know that?

A             It is part of the diagnosis; yes, sir.

Q             Is it the hallmark, the essential part of that diagnosis?

A             Probably.

 

Q             All right.  You know that severe headaches are part of the diagnosis,

or, can be for pre-eclampsia?

A             They can be, sir.

Q             Okay.  Really pre-eclampsia is a cluster of symptoms?

A             Correct.

Q             All right.  These are some of the cluster; right, so far?

A             So far.

Q             All right.  Visual disturbances.  Is that part of the cluster?

A             It certainly can be.

Q             Proteinuria?

A             It certainly can be.

Q             Nausea or upper quadrant stomach pain?

A             It certainly can be, sir.

Q             Hyperactive reflexes.  Can that be part?

A             It certainly can be.

Q             And for eclampsia you can have this cluster plus a seizure, or, seizures?

A             A seizure is the defining element to make it eclampsia, sir.

Q             Okay.  You don’t have eclampsia unless you have a seizure; right?

A             Correct.

Q             All right.  Now, that night when you did an examination you knew that was there; right?

A             Eight days postpartum, sir.  Yes.

 

Q             Again, I’ll cover that.  You knew she had high blood pressure?

A             Correct.

Q             You knew she had a severe headache?

A             Let me backtrack to the blood pressure for a moment.  I knew that at the time her blood pressure was elevated.  What the cause was was yet to be determined.

Q             Sure.  But, you knew that her blood pressure was high, which is a sign or symptom of pre-eclampsia.

A             It can be.

Q             Okay.

A             It can also be a sign or symptom of many other issues.

Q             She had photophobia?

A             Correct.

Q             You didn’t do this test; did you? 

A             That’s correct.

Q             All right.  You knew she had nausea; right?

A             So she told me.

Q             But, you didn’t check for stomach pain?

A             I believe I did examine her abdomen.

Q             If you could show me where that is on the chart?

A             Let me double-check.  I don’t recall.  No, I did not.  I apologize.

Q             So, you knew nausea.  The other part of that is did not check.  Is that fair?

 

A             Correct.

Q             And you did not check if she had hyperactive reflexes; is that true?

A             Correct.

Q             Let me write that down.  Is that true?

A             Yes, that is correct.  I did not check her reflexes.

Q             All right.   How easy or difficult would it be to check her stomach to see if there was pain?

A             During the examination it’s easy enough to lay on hands if you feel it’s indicated.

Q             Well, sure.  If you feel —

A             I also didn’t —  go ahead.

Q             I mean, you didn’t do it and you must not have felt that it was indicated.

A             At that point; correct.

Q             All right.  How easy or difficult is it to check somebody’s reflexes?

A             Again, very easy during the physical exam.

Q             All right.  How easy or difficult is it to find out if someone has proteinuria?

A             Assuming the lab is available, which it is at the facility, it can be done.

Q             It’s not a big deal; is it?

A             No.

Q             All right.  If you thought seriously about pre-eclampsia you could have had a urinalysis to check to see if there was protein; is that a fair statement?

A             Sir, I think it hedges the point.  My training was that pre-eclampsia generally doesn’t occur beyond forty-eight hours after delivery.  The possibility of a pre-eclamptic state and eclampsia had run through my mind, but based on my experience and my training really, it was very unlikely to be the case because she was eight days postpartum.  So, it was on the differential diagnosis.  Someplace I vaguely remember as part of the training that you need to look at other things before you start trying to blame those symptoms on eclampsia at this point postpartum.

Q             Again, I’ll get to that part in a minute.  You knew back then that eclampsia was a deadly, dangerous disease?

A             It certainly has the potential to be; yes.

Q             Sure.  And you knew that when women go to their obstetrician during pregnancy that they check blood pressure and urine every time?

A             That’s standard.  I believe that is standard of care, although if an obstetrician sat down and told me otherwise, well, I would have to defer.

Q             You don’t want to comment on the standard of care of an obstetrician; right?

A             No.

Q             Because you’re not one?

A             Correct.

Q             But, you know that happens?

A             I know that they often times do; yes.

Q             All right.  I like charts.  I’ll call this one ‘duties of an emergency room doctor in diagnosing pre-eclampsia or eclampsia’ – all right – ‘and some

 

of the characteristics of the disease’.  It can be preventable; can it not?

A             Which one – pre-eclampsia, or eclampsia?

Q             Pre-eclampsia leading to the seizures, strokes, and coma.

A             It’s treatable.

Q             Okay.  So, it’s treatable.  Is that what you want me to use?

A             I think if we try to say that it is something that is preventable, well, obviously until you have the high blood pressure and by definition have

pre-eclampsia during pregnancy or the forty-eight hours thereafter then, by definition, it’s already in place.  It’s not preventable.

Q             Okay.  But, from something going from pre-eclampsia to eclampsia that’s preventable, or, can be?

A             Uh-huh; that’s correct.

Q             And treatable?

A             That’s correct.

Q             All right.  Should a doctor, such as yourself, be familiar with the signs and symptoms of pre-eclampsia and eclampsia?

A             I believe I already told you that I am familiar by answering your other questions, sir.

Q             All right.  Should they know what tools to use to diagnose pre-eclampsia or eclampsia?

A             I believe that’s correct; yes.

Q             Should they know who to call if they need help?

A             Do you mean a consultant, sir?

 

Q             Sure.

A             Correct.

Q             You know, and should they know, that it’s a medical emergency?  Is that correct?  Or, it can be?  How’s that?

A             It certainly can be; yes, sir.

Q             All right.  It can progress to a life-threatening situation quickly.  Should they know that?

A             If you mean pre-eclampsia; yes, sir.

Q             All right.  Severe headaches and/or visual changes frequently come before a seizure.  Should they know that?

A             When you’re talking about eclampsia, that’s correct, sir.  However, there are many other diseases in which you can see that process.

Q             Postpartum pre-eclampsia or eclampsia can be up to three to four weeks postpartum.  Is that possible?

A             Based on my training the answer is postpartum eclampsia most often occurs in the first forty-eight hours and afterwards is much, much less likely.

Q             Okay.  My question was — well, you’re not saying it can’t happen; right?

A             Again, my training was in the first forty-eight hours post delivery.

Q             Well, did you back on August 8th think that you couldn’t get postpartum eclampsia if it was greater than forty-eight hours?

A             That was my understanding based on my training, sir.

Q             Okay.  The medical management for eclampsia/pre-eclampsia as it pertains to the mother is the same before or after delivery of the child.  You

 

know that; don’t you?

A             I know that in general it can be, but there are other drugs that may be used postpartum that if the mother is not breastfeeding might also be used to control blood pressure that wouldn’t be considered if she were, or if she were still pregnant.

Q             One more chart.  I’ll call this ‘care and treatment for pre-eclampsia/eclampsia’.  Magnesium Sulfate.  Did you know that was the drug of choice back then?

A             Yes.

Q             Okay.  You phrased it something like you vaguely remember seeing some reports on the use of Magnesium Sulfate when your deposition was taken.

A             I’m sorry?

Q             Do you have your deposition?

A             No, I do not.

Q             You have reviewed it; I assume?

A             The deposition?  Yes, sir.

Q             All right.  This was taken, let’s see, November of 2000.

A             If you say so, I believe you.  It sounds about right.

Q             All right.  You had a chance to read it over and sign it.  I think that process took awhile and you finally read it over and signed it back in March of 2001?

A             I thought I returned it more quickly than that.  But, again, if you say so, I believe you.

Q             Okay.  On page seventy-seven I asked the question, to get to where I’m at, to put it in a context – “Okay.  If you had a patient who had a diagnosis of pre-eclampsia in the emergency room how would you treat them?” 

Answer – “Known to be pre-eclamptic before that individual presented?”

Question – “Or you considered them to be pre-eclamptic.”  Answer – “If I considered them to be pre-eclamptic obviously the blood pressure would need to be reduced.  I believe the drug of choice is still Hydrozoline.  That can be administered I.V. or P.O. by mouth.  I’m sorry.  I shouldn’t use medical leads.”  Question – “Okay.”  Answer – “That’s considered typical therapy.”  Question – “Okay.”  Answer – “There are also — I vaguely remember seeing some reports of the use of Magnesium.”  Question – “Magnesium Sulfate?”  Answer – “Correct.”  “So, those are the two main line drugs?”  Answer – “From what I recall; yes, sir.”

A             Let me backtrack.  In your original question to me right now did you ask me if it was the treatment of choice for the blood pressure, or the treatment of choice for seizures?

Q             There wasn’t any seizures; was there?

A             Not the day that she saw me, no.

Q             Not yet.  It’s the treatment of choice for pre-eclampsia.  That was my question.

A             I believe the treatment of choice for pre-eclampsia is blood pressure lowering and —

 

MR. HUFFMAN:   Excuse me, Judge.  I think in all fairness Mr. Morgan should read the question which prompted that answer, which does not include the question he’s talking about here.

THE COURT:   I think the witness was going back to the question not from the deposition, but from the question asked before the deposition.  So, yea, be careful in the use of — if you’re going to use the depositions make sure that you use them accurately.

MR. MORGAN:   I quoted word for word, your Honor.

MR. HUFFMAN:   Well, how about —

MR. MORGAN:   No, no.

MR. HUFFMAN:   I’m just giving him a copy of the deposition.

MR. MORGAN:   Oh.  Great.

MR. HUFFMAN:   My objection, Judge, is —

MR. MORGAN:   What’s he objecting to?

MR. HUFFMAN:   My objection is that to fairly construe the answer one needs to look at the question which was asked, which has got nothing to do with eclampsia.

MR. MORGAN:   The question I asked?

MR. HUFFMAN:   No.  The question in the deposition.

THE COURT:   If that’s the objection, well, that’s what I’m getting at.  If you’re going to ask him to recall testimony at a deposition make sure that it’s read accurately.  If that wasn’t done, then the objection is sustained.  If that was done, then the objection is overruled.

MR. MORGAN:   Okay.  Thank you.

Q             Vaguely remember is a little different than what you’ve heard and what you know the testimony to be on Magnesium Sulfate, right, concerning

pre-eclampsia?

A             Certainly from the testimony here, sir; yes.  I’ve listened to all of the witnesses.

Q             Now, am I correct that you thought that you could not have postpartum pre-eclampsia unless there was hypertension or complications of pregnancy and delivery?

A             During what time period, sir?  Again, my training was generally in the first forty-eight hours that it was more common, and then after that you had to look to other causes for a headache or other issues – even seizure.

Q             So, my question — all right.  Well, you want to keep it forty-eight hours.  In forty-eight hours you don’t have to have a complication, or hypertension. But, you thought after forty-eight hours you have to have evidence of a problem during pregnancy in order to have postpartum eclampsia?  Is that what you thought?

A             Generally, it was my understanding that women who had problems during the pregnancy, such as pre-eclampsia, certainly can have eclamptic problems afterwards if it’s not monitored closely and appropriately treated.

 

To arive de novo, meaning without any previous problems, it’s my

understanding that that was an incredibly rare circumstance.

Q             Well, not incredibly rare, but that it could not happen.

A             I don’t remember a hundred percent what I said in the deposition because I haven’t reviewed it in a couple of days.  Do you have a specific reference you’re aiming at, sir?

Q             Page seventy-one.

A             Seventy-one?

Q             Yes. 

A             Which line, sir?

Q             Line seventeen.  Question – “Would you agree that late postpartum eclampsia may occur without a history of pre-eclampsia during the pregnancy itself?”  What was your answer?

A             My answer was – “Yes, it can, within the first forty-eight hours postpartum.”  Oh, I’m sorry.  Did you want me to read the whole answer?

Q             Yes.  Question – “Would you agree that late postpartum eclampsia may occur without a history of pre-eclampsia during pregnancy itself?”  What was your answer?

A             “Within the first twenty-four to forty-eight hours the answer is yes.  If you want to include that the period up to ten days postpartum I have to say that based on my” — I’m sorry — “I’d have to say not, based on my training.”

Q             All right.  Now, pre-eclampsia was on your differential diagnosis; is that your testimony?

 

A             That’s correct.  I did consider it.

Q             All right.  Did you feel that you had to have edema in order to —

A             It is —  I’m sorry.  I didn’t mean to cut you off.

Q             Did you feel that you had to have edema, swelling, in order to diagnose pre-eclampsia back then?

A             Edema certainly can be part of the syndrome, but it’s not a requirement.

Q             Could you look at your chart and tell me —

A             The chart?

Q             — where you checked to see if edema was even there, or not there?

A             I guess it depends on how you want it phrased, sir.  What I did, was under ‘skin’ it says ‘normal texture and turgor’.  It should be the third page – under ‘skin’ under ‘physical examination’. 

Q             Is there a spot for edema?

A             I’m sorry?  I don’t understand the question.

Q             Well, is there a spot that says edema?

A             Specifically?

Q             Yes.

A             No.  Skin turgor is a description.

Q             No.  On the chart.

A             I’m sorry?

Q             Would you look at the chart where it asks about whether there’s edema, or not, and tell me what’s checked, or not checked?

 

A             Are you talking about on the nurse’s notes, sir?

Q             Yes.

A             Okay. 

Q             Let me point it out.

A             That would be helpful.

Q             Edema.  There’s a big line there; right?

A             This is on the nurse’s notes, sir.  The nurse did not comment one way or the other.

Q             Okay.  Well, did you say in your part that she had edema, or did not have edema?

A             I said the skin had normal texture and turgor, sir.  Turgor is a fancy way of saying is it swollen, is it puffy.

Q             So, skin is swelling to you?

MR. HUFFMAN:   Judge, I object to that.

Q             Is that right?

MR. HUFFMAN:   That’s not what he said.

MR. MORGAN:   I’m trying to clarify it.

THE COURT:   The objection is overruled.  He’s asking a question.

A             Certainly you can document it there, sir.

Q             All right.  At any rate, you know you don’t need edema?

A             That’s correct.

Q             Okay.  Now, do you agree with Doctor Snyder, Doctor Yalch the emergency room doctor, and Doctor Snyder is the doctor who will be testifying — you’ve read his deposition; haven’t you?

A             Yes, I have.

Q             All right.  Doctor Gilbert.  Doctor Porter.

A             I have not read Doctor Gilbert deposition.

Q             You heard his testimony, though?

A             Yes, I did.

Q             He way the gray-haired obstetrician.

A             Yes.  Yes, I know who you’re talking about.

Q             And you’ve read Doctor Porter’s deposition?

A             Yes.

Q             And you’ve read Doctor Sinai’s deposition?

A             That’s correct.

Q             Didn’t each of those doctors talk in terms of weeks that postpartum pre-eclampsia can occur – from two weeks to six weeks, and not hours like you have said?

A             What I know is that certainly Doctor Yalch and Doctor Gilbert had done so.  I don’t remember Doctor Snyder, to be perfectly honest, sir.  I haven’t reviewed that deposition in I’m going to guess at least six months, if not longer.  Doctor Sinai, again, I don’t remember.

Q             If Doctor Snyder says that an emergency room doctor should know that prepartum (sic) eclampsia can occur up to three weeks would you agree with that?

 

A             That was not my training, sir.

Q             Your training, or, what you’re telling me your training is was forty-eight hours; right?

A             Correct.

Q             Now, if you needed help you could have looked it up in the textbook to find out the timing.

A             Only if one is available.  Only if one is available, sir.

Q             Well, isn’t there texts available?

A             I don’t remember which texts were available, if any, to be honest with you.  There’s usually a small library, but sometimes they get to be several editions old and so the information is not necessarily as current as it could be.

Q             But, you could go on-line and check; couldn’t you?

A             No.  As far as I know that capability was not available  .

Q             Could you have asked any of the two hundred partners that you have?

A             I guess it’s always possible to have done that.  Yes.

Q             But, you did not?

A             That’s correct.

Q             All right.  I want to go by your way of thinking here on forty-eight hours.

A             All right.

Q             Isn’t there a clear-cut sign that even you would say that it could happen greater than forty-eight hours?  A test that you could do?

A             If you’re asking proteinuria, there are many things that can give you protein in the urine, including contamination with blood, sir.

Q             Is the answer to my question that proteinuria is a test that —

MR. HUFFMAN:   Excuse me, Mr. Morgan.  Could you stand so that I could see him while he’s testifying?

MR. MORGAN:   Sure.

MR. HUFFMAN:   I appreciate that.  Thank you.

Q             Proteinuria is a test that even you would agree that’s clear-cut after forty-eight hours?

A             No, sir.  The way you’re phrasing that question it implies that to do it, well, if it’s positive then you have a definitive diagnosis.  The answer is no, that you have a number of potential diagnoses.

Q             I’m trying to do according to what you said.  I’d like you to turn to page sixty-six or sixty-seven.  Page sixty-six, like twenty-two.

A             Line twenty-two?

Q             Are you there?

A             Yes, I am, sir.

Q             Okay.  Question – “Okay.  Hypertension, proteinuria, and convulsions that occur later than forty-eight hours, but before ten days postpartum, are typically referred to as postpartum eclampsia.”  Your answer was – “I am aware of the term postpartum eclampsia.  I have not heard it applied to anything that happened up to ten days without clear-cut diagnostic – how can I say it – without clear-cut evidence to prove that it was related, that it was a

 

pregnancy related issue.”  Question – “How would you get the clear-cut

evidence?”  Answer – “I would want to see evidence of proteinuria.”  Right?

MR. HUFFMAN:   Well, Judge, I’m sorry, but that’s not a complete answer.

MR. MORGAN:   Well, I’ll keep going.

Q             “I would want to see evidence of peripheral edema.  A patient who is hypertensive and has a seizure need not have eclampsia or have had pre-eclampsia.”  Was that your answer?

A             That’s correct.

Q             You did not do a proteinuria test; did you?

A             No, I did not.

Q             Again, your way of thinking, you attributed all of her symptoms to sinusitis; is that correct?

A             It certainly can be associated with sinusitis.  Yes, sir, in her case I believed it was.

Q             You would describe her sinusitis as mild, or a small amount?

A             I’m sorry?  In what context?  How much pain it caused her, or how it looked on —

Q             In terms of what you claim, or, what you say you saw on the C.T. scan.

A             What I thought I saw on the C.T. scan was a small amount of change.  That doesn’t describe how much it might hurt.  But, yes.

Q             Did you describe it as mild and a small amount?

A             I don’t remember the exact words.  If you would like, I can look it up.

 

Q             Page fifteen and sixteen.

A             I guess I have a different numbering system, sir, so give me a moment.

Q             Sure.  Take as much time as you need.

A             I’m sorry.  I was looking at the interpretation of the C.T. scan.

Q             On the very last line.

A             Of the C.T. scan?  Oh, okay.  “The bone windows show evidence for mucoid material in both frontal sinuses.”  Is that what you’re talking about, or are you talking about a different spot?

Q             I’m talking about line twenty-five.

A             Oh, twenty-five in this?

Q             On page fifteen.

THE COURT:   Are you reviewing the chart, or the deposition?

MR. MORGAN:   The deposition.

A             Oh, the deposition?  I’m sorry.  I thought you said the chart.  I apologize.

Q             I might have said that.  I don’t know.

A             I’m sorry.  So, that’s page fifteen again?  Is that right, sir?

Q             Yes.  Page fifteen, the last line.  Just so we’re clear.

A             Do you want me to read this?

Q             Well, my question was – did you characterize it as mild?

A             Mild mucoid material within the frontal sinuses is what I had thought.

Q             Okay. 

 

MR. HUFFMAN:   Excuse me, Judge.  I wonder if he could read the entire answer.

A             That’s fine.

MR. MORGAN:   I mean, that’s up to him.  He answered.

THE COURT:   Well, it’s not.  There was a question here that was asked, and he answered the question.  You’ll have a chance to ask him questions, too.

Q             So, your way of thinking, Doctor, is that this mild small amount of sinusitis caused the worst headache of her life and the pain which led to high blood pressure, nausea, and photophobia, the things you checked and knew about?

A             I think there’s a misperception there.  The amount of abnormality that you see on a CAT scan doesn’t always correlate with the clinically perceived symptoms.

Q             Sure.  As a matter of fact, the radiologist that read this x-ray read that it was completely normal; didn’t he?

A             That’s correct.

Q             And they’re trained to just do that, to read x-rays?

A             That’s correct.

Q             Looking at your way of thinking, she could have sinusitis and still have pre-eclampsia.  Couldn’t there be more than one disease process going on at the same time?

 

A             It is uncommon, but possible.

Q             Okay.  She could still have sinusitis and a life-threatening disease?

A             It is certainly possible; but, again, two disease entities presenting at the same time are unusual.

Q             Yea, but you thought of it.  You put it on your differential; right?

A             That’s correct.  But, that doesn’t necessarily mean that I felt that it was at the top of the differential as I worked my way through it.

Q             Well, going back to this very first chart.  When you have something that could be sinusitis, and something that could be pre-eclampsia, well, it begs the question that sinusitis is not on the same level as pre-eclampsia, is it, in terms of danger?

A             Potentially?  No.  I think that pre-eclampsia has more likely to move on.  But, people have had severe outcomes from sinusitis although, granted, very infrequently.

Q             You didn’t even see that; right?

A             I’m sorry?

Q             You didn’t see that on any x-rays or any of your clinical findings – severe sinusitis?

A             No.

Q             So, you’ve got sinusitis and pre-eclampsia.  How did you justify pointing towards sinusitis when you look for life-threatening things and try to rule that out?

A             Well, as you imply there, the differential diagnosis is not a status entity.  It starts out with your initial impression based on history and physical examination.  Sometimes, or, often times there’s retrospection, or, thoughts about the process.  Can I rule this in, or out, based on what I did, or didn’t find, in this particular patient?  Based on the fact that she was eight days postpartum I felt that the likelihood of eclampsia or pre-eclampsia had moved down on the differential diagnosis for its original position.

Q             You ruled pre-eclampsia in by having it on your differential diagnosis; correct?

A             I’m sorry?  Ruled it in?

Q             Ruled it in because it was on your differential diagnosis.  It was possible that she had that.  Isn’t that what differential means?

A             I would agree to that; yes.

Q             You’ve read these depositions.  I asked both of the doctors defending you – ‘was there anything on this chart that ruled it out’ – and they said no.  Do you agree with that?

MR. HUFFMAN:   Excuse me.  I object to the question.  It’s not clear whether he agrees that they said that, or whether he agrees with that statement.

MR. MORGAN:   I’ll ask both, Judge, just to make it clear.

Q             Do you agree they said that?

A             I don’t remember.

Q             Well, do you agree it’s true?

 

A             That there’s nothing there that rules it out?  The fact that she’s eight days postpartum pushes it way down on the differential diagnosis.

Q             I didn’t say pushes it way down.  I said rules it out.

A             No.

Q             Right before she went home you checked, or, well, I don’t know if you checked it or caused her blood pressure to be checked; right?

A             The blood pressure was checked; yes, sir.

Q             All right.  Again, your way of thinking was that the pain from the sinusitis was causing the problems.  We’ve covered that.  Right?

A             It certainly could be causing all of it; yes.

Q             You gave her a shot of Demerol, which is a narcotic, to reduce the pain?

A             Correct.

Q             The pain was reduced; was it not?

A             Yes, it was.

Q             The blood pressure went up?

A             Yes, at the time that it was taken.

Q             At eight-fifteen.

A             If you say it was eight-fifteen; yes.

Q             Well, how did that make pre-eclampsia go down and sinusitis go up on your differential diagnosis?

A             There are many things that can cause an elevation in blood pressure, sir – from pain, to anxiety, to worry about getting home.  It could have also been the technique that was used to perform the blood pressure.  So, no, it

doesn’t make a difference in the differential diagnosis.

Q             It didn’t mean anything to you?

A             I didn’t say that.

Q             Well, if it doesn’t make a difference — did it mean something to you that her blood pressure went up to one seventy-six over eighty?

A             Yes.  I thought it was due to other causes, as I just pointed out.

Q             Even though you gave her a narcotic and the pain went down?

A             Well, again, she didn’t express to me whether or not she was worried about getting home to the children.  She had a young baby at home and maybe it was time to be fed.  There are a number of things that could have caused it.

Q             All right.  Wanting to go home to get a baby fed versus a dangerous pre-eclampsia —

A             I can’t tell you which caused the elevation in her blood pressure, sir.  I know what I was thinking at the time.

Q             Okay.  Well, at any rate, you told her, after all this was said and done, to wait.  Wait three or four days and if it wasn’t better then have it re-checked.

A             I think there’s an addition to that.  I also told her that if she was having worsening symptoms, despite what we were doing, that she should be re-checked in a more timely fashion.

Q             Okay.  But, if she wasn’t having worsening symptoms she was to wait.

A             Agreed.

 

Q             Did you tell her that pre-eclampsia, that she had signs and symptoms

of it, and that it was on your differential diagnosis?  Did you tell her that?

A             I don’t believe I discussed differential diagnoses with her at all.

Q             Why not?  She’s the patient; right?

A             I don’t think I would discuss differential diagnoses with most of my patients, sir.

Q             Okay.  Did you tell her that someone with signs and symptoms of

pre-eclampsia and someone with severe headaches or visual changes frequently come before a seizure?  Did you mention that to her?

A             No, I did not.

Q             You sent her home.  You did not treat the pre-eclampsia; is that correct?

MR. HUFFMAN:   Excuse me, Judge.  I object to that.  There’s no evidence here that there was any pre-eclampsia.

MR. MORGAN:   He didn’t treat it, your Honor.

THE COURT:   Well, I think the objection will be sustained.  You can ask that another way.  So, I’ll sustain it the way it was asked.

Q             Okay.  The pre-eclampsia that we’ve talked about and that was on your differential diagnosis, did you treat that?

A             I don’t believe the patient had it at the time and so, no, I did not treat it.

Q             You did not do any protein or lab work urinalysis?

A             That’s correct.

 

Q             You did not check her stomach?

A             I did not palpate the abdomen or do an abdominal exam; that’s correct.

Q             You did not check her reflexes?

A             That’s correct.

Q             You sent her home?

A             Yes.

Q             To wait?

A             To see if the intervention for the process that I thought was on-going would be successful as the Amoxicillin had not.

MR. MORGAN:   That’s all I have at this time, your Honor.

THE COURT:   Okay.  Doctor, you may step down.  We’ll get a chance to hear from you again later.  Why don’t counsel approach?

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s