Examination 1 - direct and cross of doctor in med mal suit
BY MR. ROBBINS:
Q. Dr. Mandel, thank you for coming today. Were you Michelle Ayala's primary oncologist from September of 1999 until she passed away on September 9th, 2000?
Q. Can you briefly explain to the jury what the specialty of oncology is and what oncologists do.
A. Medical oncologists are doctors that treat patients with cancer using chemotherapy and other injectable or orally administered modalities.
Q. Briefly, by way of background, where did you attend medical school?
A. Washington University in St. Louis.
Q. And when did you graduate?
A. In '92; 1992.
Q. And what was the next step in your medical education?
A. I did my residency at the University of Minnesota.
Q. And was it during your residency at University of Minnesota that you acquired an interest in possibly pursuing oncology as a specialty?
Q. What was the next step in your medical education?
A. I did my fellowship in medical oncology at the Cleveland Clinic.
Q. And was that from 1995 till 1997?
Q. Can you tell the jury a little bit about what a fellowship in oncology is.
A. A fellowship in oncology is a training period much like a residency with a focus on medical oncology; basically all you do is medical oncology.
Q. Doctor, in July of 1997, did you join North Shore Oncology/Hematology Associates?
Q. And how many doctors approximately are in that practice?
A. At that time I was the fourth doctor. There's currently six.
Q. And are all of you oncologists and/or hematologists?
Q. So you had been there approximately two years at the time Michelle Ayala became your patient?
Q. At that time you were on the staff of Good Shepherd Hospital?
Q. And you presently remain on the staff there, and also, I think, there's few other hospitals. What are they as well?
A. Also Lake Forest Hospital, Condell Hospital, and Northern Illinois Medical Center.
Q. At that stage in your career, in private practice about two years, was Michelle one of the younger patients in your practice with ovarian cancer?
Q. Was she the youngest patient?
A. Yes, I believe so.
Q. And in the last five or six years, have you seen anybody younger?
Q. I gather that Michelle made somewhat of an impression on you.
Q. Can you tell the jury a little bit about what you recall about Michelle as a person.
A. Very nice person. Very personable. I think, you know, basically she was a typical 19-year-old, you know, with the same kind of interests a 19-year-old would have.
Q. Was she a fighter, Doctor?
Q. Was she an optimist?
Q. Is there anything that you recall that causes you to remember her being a fighter or an optimist, anything in particular?
A. Basically she was willing to undergo any chemotherapy regimen that was a possible help to her. She didn't want to forego treatment.
Q. Doctor, tell us in general what her general course of treatment was with you.
A. When she was first diagnosed, she had cancer that had spread to the spine, and so she S started with radiation therapy to the spine. Upon completion --
Q. Can I stop you right there.
Could you tell us a little bit about what radiation therapy is.
A. It's a -- it's a therapeutic radiation that's basically using isotopes that are beamed externally to certain tissue or bone structure.
Q. Go on, Doctor.
A. I didn't do that. The radiologist/15 oncologist did that.
But after she was done with that, then I started my treatment, which was the use of chemotherapy.
Q. Let me stop you right there.
What was the -- not the first date, but what was the first month that Michelle received any chemotherapy?
A. Can I just check?
A. Her first date of chemotherapy was October 26, 1999.
Q. And this would be about one month after she became your patient?
Q. Can you tell us what the first chemotherapy course was.
A. It was a combination of Carboplaten and Taxol.
Q. Can you tell us a little bit about Carboplaten and Taxol.
A. It's a standard regimen, first-line regimen for ovarian cancer. It's injectable. It's given over about three and a half hours every three weeks --
Q. When you say --
A. -- as an outpatient.
Q. When you say that's a standard regimen, is that something well known throughout the industry?
Q. Is that something that's written about in textbooks?
Q. Can you go on and tell us approximately how long she had the Carboplaten and Taxol or how many cycles.
A. She received three cycles.
Q. What was the next chemotherapy that she would have received?
A. It was a combination of three drugs; one is 5-fluoracil, the other is Leucovorin, and the third is irinotecan or CPT-11.
Q. By the way, did the Carboplaten and the Taxol make any significant difference?
Q. What about the second course of chemotherapy?
A. At the end did it make a difference?
A. No, it didn't.
Q. Was there any additional chemotherapy after that second course of chemotherapy?
Q. What was the third combination of chemotherapy?
A. The third combination was Doxcil.
Q. And did Doxcil work at all with regard to Michelle's cancer?
Q. Was there any additional chemotherapy tried on Michelle?
A. Yeah. She then received oral VP 16, and then after that she received Gemzar.
Q. Would it be fair to say that you tried five different chemotherapy regimens over this 12-9 month period to try to help Michelle?
Q. Was any of that chemotherapy significantly effective?
Q. Doctor, was any surgery performed on Michelle at all during that 12 months that you treated her?
Q. Can you tell us about that.
A. She had an iliopsoas release surgery done at Loyola.
Q. What is -- can you tell us what type of surgery that is in general.
A. Basically the iliopsoas muscle is a muscle that goes from the spine to the leg. And she had a contracture deformity. And so the purpose of the surgery was to release that contracture deformity.
Q. Was that contracture deformity preventing Michelle from ambulating normally?
Q. And was that surgery successful?
A. She still didn't walk normally after that.
Q. And what caused this contracture deformity?
A. I don't honestly know.
Q. Was Michelle hospitalized at all during these 12 months that she was your patient?
Q. Approximately how many times?
A. Approximately -- I can find out for sure.
Q. An approximation is --
A. Approximately four or five perhaps.
Q. Can you give us a sense in general of why Michelle would have had to have been hospitalized during her 12-month battle with this cancer?
A. She had problems with pain control. She had problems with nausea and vomiting. She had problems with nutrition. She had problems with shortness of breath. Abdominal distention. She had a blood clot. So they were various reasons that she was hospitalized. It may have been more than four or five. Again, I car get that information for you.
Q. Doctor, when Michelle was your patient, was she a compliant patient at all times?
A. Very much so.
Q. Did she do what was asked of her medically?
Q. How about her family, do you remember Michelle's family?
Q. Were they a compliant family? Did they do what was asked of them medically?
A. Everything. Very supportive.
Q. Doctor, what did Michelle die from on September 9th, 2000?
A. She died of low blood pressure; hypotension.
Q. And what was the general medical problem that she had that caused other problems?
A. You mean the cancer?
Q. Yes. What was the nature of her cancer?
A. Well, she had the ovarian cancer.
Q. And that was metastatic ovarian cancer?
Q. And that -- in turn, did that metastatic ovarian cancer lead to other more specific complications?
A. Everything I talked about. She had complications of the therapy with low blood counts. She had problems with the weakness and the fatigue and the nausea and the pain from the cancer. She had the blood clot. Yes.
Q. Ultimately, was it the metastatic ovarian cancer that was responsible for the specific medical things which led to her death?
Q. Doctor, the origin of Michelle's metastatic ovarian cancer was the ovary?
Q. And where had that ovarian cancer spread to at the time Michelle first became your patient in September of 1999?
A. To the lungs and to the bone of the spine.
Q. And what stage was that ovarian cancer when she first became your patient in September of 1999?
A. Stage 4.
Q. And that stage 4 you mentioned, was that FIGO stage 4?
Q. Doctor, based on the location of the mets in the lung and the bone when Michelle first became your patient, do you have an opinion to a reasonable degree of medical certainty as to what the mechanism of spread of Michelle's tumor was from the ovary to her lung and to the bone?
A. Hematogenous, through the blood most likely.
Q. Is hematogenous spread or blood borne spread also known as vascular spread?
MR. ROBBINS: No further questions, your Honor.
THE COURT: Ms. Becker -- Bacher. Sorry.
BY MS. BACHER:
Q. Good afternoon, Doctor.
Q. Dr. Mandal, you are board certified in internal medicine, correct?
Q. You're board certified in oncology, correct?
Q. And you perform chemotherapy on patients, right?
Q. You administer the drugs, you determine the modalities of how these patients are treated, correct?
Q. And just to clarify a couple points. Five different chemotherapy regimens were tried on this tumor, and none worked, correct?
Q. Five different drugs or combinations of drugs were used on this tumor, and they didn't work, correct?
A. Is that the same question?
Q. Basically. Just with your treatment, there were five different types of treatment you gave Michelle Ayala's tumor, and none of those treatments worked, correct?
Q. None of them proved to be effective on this type of tumor, right?
A. It didn't help Michelle, no.
MS. BACHER: Thank you. I don't have any questions.
MR. ROBBINS: Judge, one follow-up.
When a patient presents with stage 4 ovarian cancer that has metastasized to lung and bone, Doctor, what is the percentage of survival that that patient will have regardless of the chemotherapy used.
MS. BACHER: Your Honor, objection. Scope.
THE COURT: Overruled.
You can answer.
THE WITNESS: Could you repeat the question.
MR. ROBBINS: Sure.
When a patient presents to you as Michelle did with stage 4 ovarian cancer which had metastasized to lung and bone, what is the percentage of survival according to FIGO regardless of what chemotherapy is used?
THE WITNESS: It's incurable.
MR. ROBBINS: Thank you, Doctor.
MS. BACHER: NO questions, your Honor.
THE COURT: You may step down, sir. Thank you.