Examination 2 - direct and cross of expert witness in med mal suit
BY MR. AXELROD:
Q. Good afternoon, Doctor. Will you, please, tell us your name and spell your last name?
A. Kenneth Pursell, P-u-r-s-e-l-l.
Q. Where do you live?
A. My home address?
Q. Just what city?
Q. What do you do for a living?
A. I'm a physician.
Q. Do you specialize in any particular area of medicine;
A. I'm an infectious disease specialists.
Q. Tell us, what is the specialty of infectious disease medicine? Can you describe it?
A. Well, we're asked to consult on suspected or proven infections in a variety of patients.
Q. When you use the term “consult,” what do you mean?
A. People will ask us a particular question, and come and see the patient, examine the patient, ask to get a history, review whatever records might be available to us, and leave a note, discuss the case with the people who ask us the particular question.
Q. Where did you go to college, Doctor?
A. I went to Fairfield University undergraduate.
Q. When did you graduate?
A. In 1978.
Q. Where did you attend medical school?
A. University of Connecticut.
Q. Did you do a residency?
A. I did, in internal medicine at North Shore University Hospital, Manhasset, New York.
Q. What is internal medicine? Did you do a residency in it, so can you describe it for the jury?
A. So it's a -- internal medicine is basically adult medicine. You're taking care of -- it's the general internist who deals with, you know, adults, you know, in health and in illness within your field of expertise.
Q. Doctor, how long was the residency in internal medicine?
A. Three years.
Q. Did you engage in any kind of fellowship after you completed your residency?
A. I did. I did an infectious disease fellowship.
Q. Where was that?
A. At Memorial Sloan-Kettering Cancer Center in Manhattan.
Q. How long was that fellowship for?
A. Three years.
Q. What year did you finish your fellowship?
Q. Can you describe for the jury what's involved in a fellowship program for infectious disease?
A. Sure. They're kind of all structured in a similar fashion. Your first year is spent in a fairly -- as a clinical year, where you see all the consults that are called in the hospital which usually takes about ten months of your first year. You do a month of training in a microbiology lab. You get a couple of weeks vacation. The second year is spent sometimes, depending on how your program is structured, but you spend more time trying to develop a research program, a research protocol rather, that you're going to study, and that, at least where I was, that extended over the two-year period.
Q. You currently practice at what hospital?
A. University of Chicago Hospitals.
Q. When did you come to University of Chicago?
A. September 2002.
Q. From the time you finished your fellowship in 1991 until September of 2002, what did you do?
A. I was an infectious disease specialist at University of Illinois at Chicago.
Q. Have you been an infectious disease specialist at the University of Chicago since you came here?
Q. You indicated before that infectious disease physicians consult. Is that all you do is consult?
A. No, I also have a group of patients that I follow as their primary care, their primary doctor. Almost all of those are HIV infected patients.
Q. Are you board certified in any areas?
A. I'm board certified in internal medicine, and I'm board certified -- I'm board eligible now in infectious disease. My board in infectious disease ran from 1990 to December, December 2010, and I'm taking a recertification exam in a month.
Q. What does it mean to be board certified, Doctor?
A. The American Board of Internal Medicine, the ABIM, is the governing body that provides certification based on their guidelines. So you have to apply to be certified, and you have to have completed a certain training program, and then you have to complete -- you have to take tests in order to be certified.
Q. Do you teach in the area of infectious diseases?
A. I do.
Q. Tell us about your teaching responsibilities.
A. I have teaching responsibilities with our fellows that are trainees in infectious disease. I have teaching responsibilities with our internal medicine residents. I have teaching responsibilities with the medical students. And for an unclear reason, I've been involved in an undergraduate course also for the past several years.
Q. Is all your teaching in the area of infectious disease?
Q. How long have you been teaching in the area of infectious disease?
A. Pretty much since I started, 1991, '92. That was part of my -- it's been part of the job since the beginning.
Q. Do you have an official title at University of Chicago?
A. Professor of Medicine.
Q. How long have you been a professor of medicine?
A. Since February of 2009 I believe.
Q. Is there a kind of pecking order where you start and you go to become a professor?
A. Oh, yes.
Q. What's the pecking order?
A. So you start off as an instructor, then you're an assistant professor, an associate professor, and then a full professor.
Q. And you've now been a full professor for about two years, right?
A. Yeah, I think that's right.
Q. Doctor, you provided or did a consult on Irene Carter on February 4, 2003; is that correct?
Q. Do you specifically remember Irene?
Q. Have you reviewed anything in preparation for your testimony today?
A. I've reviewed my consult note that I had, and I reviewed the deposition that I've given in 2007.
Q. In front of you is what's been marked as Plaintiff's Exhibit Number 27. Can you identify this document?
A. This is the consult that I did on February 4, 2003.
Q. For Irene Carter?
A. Yes, for Irene Carter.
Q. What was the purpose of you being brought in for this consultation?
A. The question we were asked was the source of her bacteremia, she had bacteria in her bloodstream, and recommended management of that.
Q. Is the definition of bacteremia meaning bacteria in the bloodstream?
Q. Is another word for that infection?
A. I think it's under the umbrella of an -- would say yes. I don't independently recall that, but from the note, yes.
Q. What are gangrenous toes?
A. Well, they're essentially dead, dead toes, dead digits, usually from some sort of vascular compromise. She's not getting good enough blood flow there, so ultimately these toes have died.
Q. And in the right-hand shaded area on the first page, there's some writing there. That's your writing as well?
A. The word “sedated,” yes.
Q. The rest of the writing is by somebody else?
Q. Who would have been doing the rest of the writing?
A. It would have been one of the internal medicine residents that was rotating through on the service at the time.
Q. Is that the practice at University of Chicago for a consult like this is that the resident writes the initial notes, and then you write your own conclusions after that?
Q. Is that what you did with Irene's consult?
Q. Can you read, starting from where it says “CC,” what was written by the resident, please?
A. Sure. Would you like the whole top part?
Q. Just start. If I have a question, I'll interrupt and ask you a question.
A. Can I ask you a question? There's a lot of medical shorthand here. Do you want me to read it out, or just what's written here read?
Q. Read it out, please.
A. Okay. So CC, question, source of bacteremia/antibiotic coverage.
Q. So that was the purpose of the consult was to determine the source of the bacteremia and recommend an antibiotics coverage?
Q. Go on under -- what's “HPI” by the way?
A. History of present illness.
Q. Could you read what it says there, please?
A. I'll try. Patient is a 77-year-old -- I can't see that.
Q. Is that white female?
A. It might be WF. If it says “WF,” it would be white female, with history of endstage renal disease on hemodialysis. I don't know what the next -- I can't read the next thing. I think it's hypertension, who presented to outside hospital, I think it says Holy Cross on 1-3 with cough, diarrhea, and lower abdominal cramping, status post missing hemodialysis. Patient was empirically started on Zosyn.
Q. What's Zosyn?
A. It's an antibiotic.
Q. Please, continue.
A. Patient underwent CT scan 1-20 at the outside hospital showing partial small bowel obstruction, extensive DVT in the right iliac veins and inferior vena cava.
Q. Let's start for a second.
Q. What's a CT scan?
A. It's a much more sensitive radiographic imaging than just a plain front back X-ray. It's sort of a computer regeneration of a number of different images that gives you just much better resolution as to what area of the body you're looking for.
Q. What's a small bowel obstruction?
A. Well, it's sort of -- it's -- there's evidence on the CT scan that the small bowel is dilated more than it should be and it's not the proper caliber that it normally is. So it's suggestive that there is some form of obstruction, whether it's mechanical or physiologic, that the bowel itself is not performing peristalsis properly.
Q. Do you know whether or not at Holy Cross Hospital Irene Carter was, in fact, diagnosed with a small bowel obstruction?
A. Do not.
Q. Based on review of your consult, do you understand that Irene was transferred from Holy Cross Hospital to University of Chicago Hospital?
A. Can you say that again?
Q. Do you have any understanding as to whether or not Irene was transferred from Holy Cross Hospital to University of Chicago Hospital?
A. She was.
Q. That was my question. It was just confirming that was your understanding, right?
Q. And then it says “Extensive DVT.” First of all, what is a DVT?
A. It's a deep vein thrombosis where she had a clot extending from her iliac vein into her inferior vena cava.
Q. When was that found according to the CT scan?
A. I think it was January 20. I think.
Q. Then after -- go on. “CBD dilatation,” what's that?
A. Common bile duct, which there's some dilatation in the bile drainage of the liver.
Q. Please, read on.
A. “Possible course unclear. Patient became septic, transferred to the medical intensive care unit, intubated, and trached. Positive disseminated intravascular coagulation.”
Q. What is that?
A. It's generally a manifestation of a rather severe infection. It doesn't have to be caused by an infection, but there's a number of other reasons for that. But it shows that there is an abnormal clotting process going on in this patient at that particular time.
Q. Did you come up with any conclusion as to what caused the DIC, the coagulation in Irene?
A. No, we did not.
Q. Do you know whether or not they came to that determination at Holy Cross Hospital?
A. I do not know.
Q. Next it says, “Positive MRSE.” What's that?
A. That is a methicillin resistant staph epidermitis.
Q. What is that?
A. That's a bacteria that's commonly on her skin.
Q. Read on, please.
A. That's part of the same thing. “Positive MRSE blood cultures. Fungal blood cultures positive for candida on 1-25,” I believe that is.
Q. Candida, what is that?
A. It's a yeast.
Q. Keep going, please, Doctor.
A. Then I don't know how this -- whether this is 1 of 3 or -- I don't know what that is.
Q. 1/3, January 3rd?
A. I don't know if it's January 3 or 1 of 3, but it might be January 3. It's “1/3, blood culture with VRE,” Vancomycin-Resistant Enterococcus, and then in parentheses “Linezolid susceptible.”
Q. What does that mean?
A. That whole phrase means that she had this particular enterococcus, which is a bacteria, in her bloodstream which happens to be resistant to vancomycin, which is a common antibiotic used to treat enterococcus. And then in parentheses he notes that it is, however, susceptible to Linezolid, which is an another antibiotic that would be used to treat VRE. So it is susceptible to that.
Q. Please, continue, Doctor.
A. “Positive enterobacter blood cultures. Patient transferred on Linezolid 600 milligrams intravenous every 12 hours.”
Q. So at the time that she was transferred from Holy Cross to University of Chicago, what antibiotic was she on?
A. She was on others. She was -- Linezolid was one, diflucan 400 milligrams intravenously every 48 hours. I'm still reading here.
Q. Okay. Please, go on.
A. “Patient also received Tequin and Gent,” both of those are antibiotics, “at some point at the outside hospital. Course also complicated by bradycardia with a ventricular pace” -- I think a temporary ventricular pacer placed.
Q. What does that mean?
A. She had abnormal rhythms of her heart, and she had a wire inserted into her heart to ensure that her heart rate was adequate.
Q. If that word is temporary, what does that mean?
A. That means that that can be removed.
Q. Do you know whether or not the pacemaker --
A. I don't.
Q. So you don't know whether or not, first, there was actually a pacemaker inserted at Holy Cross Hospital, or whether or not it was subsequently removed?
A. Well, according to my note, the pacemaker, the temporary pacemaker was placed at Holy Cross Hospital. Whether it was removed or not, I can't tell you.
A. I can't remember.
Q. Please go on, Doctor.
A. “PEG tube placement,” boy, I think that's 1-30.
Q. What's a PEG tube?
A. It's a percutaneous -- it's a tube that's placed into the stomach through the skin to ensure adequate nutrition.
Q. So if somebody's having trouble eating, it's to help feed them?
A. Yeah, it's usually -- yes.
Q. Please, go on.
A. “Patient transferred to University of Chicago Hospital on February 1, 2003. Patient had an infected” -- I can't read the next word.
Q. Is that exposed?
A. I can't. I don't know. “Right arm AV graft removed on February 2, 2003.”
Q. So was the infected right arm AV graft removed at University of Chicago as far as you understood?
Q. What is a right arm AV graft?
A. So it's a graft, which is a piece of material that connects an artery to a vein that's used for hemodialysis access.
Q. Go on, please.
A. “University of Chicago Hospital course complicated by atrial fibrillation. Underwent bronchoscopy with bronchial alveolar lavage on February 3.”
Q. What does that all mean?
A. So she developed a different heart rhythm disturbance, atrial fibrillation, and then she underwent a bronchoscopy with a lavage, which means she had a special scope put down into her lungs so that they could lavage in some fluid and remove it for -- for whatever, for examination and evaluation.
Q. And the last line?
A. “Sacral decube, Stage 3.”
Q. What does that mean?
A. That means there was an open sore on her back side area that was graded as Stage 3.
Q. Would that also be known as a bedsore?
A. Oh, yes. Yes.
Q. Please, go on.
A. “Debrided by plastics. Vascular consulted for gangrenous toes.”
Q. When it says “debrided by plastics,” what was it talking about?
A. The sacral decubitus.
Q. The bedsores?
A. The bedsores, yes.
Q. What does debrided mean?
A. At the bedside they would have tried to remove whatever, I guess, nonviable or infected tissue might be present there.
Q. On your report, Doctor, is there any indication as to whether or not you were aware of the result of a TEE, Transesophageal Echocardiogram, performed at University of Chicago on February 4, 2003?
Q. Go to the second page, please.
Q. There's a bunch of notes at the top. Why don't we start at the left under OSH. What does that say?
A. Outside hospital. I can't read the date. “Enterobacter cloacae. Resistant to ampicillin, resistant to UniSyn.” Then there's another date, it says, “candida albicans.” And then another date, I think it says January 30, that says “VRE,” Vancomycin-Resistant Enterococcus.
Q. Then there is a Number 1, lab pathology, and there's some notes under that. What are those notes?
A. Those are the labs that would have been obtained at the University of Chicago.
Q. Now, there is some of your writing on the second page, correct?
Q. Where is your writing on the second page?
A. Everything where it says -- underneath “Problems,” indicate status, workup management, treatment plan.
Q. What was the first problem that you listed?
A. Gram positive cocci.
Q. What did you put in parentheses next to that?
A. Question VRE.
Q. So what does that mean?
A. That means that her blood cultures at University of Chicago were positive for gram positive cocci, and since she did have this VRE recovered at the other hospital, I was wondering whether or not it was the same. We didn't have that identification yet.
Q. What else did you write? You wrote, “Gram positive cocci (question VRE),” then read the rest from there.
A. “Bacteremia secondary to infected AV graft removed on 2-2-03.”
Q. So explain what “bacteremia secondary to infected AV graft removed 2-2-03” meant.
A. The question to us was what was the potential focus of the infection, and at the time I thought that it was possible that maybe the graft was a possibility as the potential infection, which was removed.
Q. Then what was your recommendation for antibiotics?
A. To continue Linezolid and follow up on the platelet count.
Q. Why is that?
A. Well, Linezolid can cause depression of the platelet count which can lead to increased risk of bleeding.
Q. What was your second diagnosis?
Q. What is that?
A. That's fungus in the bloodstream. That's candida, the yeast.
Q. Doctor, is there -- according to your first note, the graft was removed on February 2, 2003, correct? Under “Problems.”
Q. Was there any lab data in your report concerning what was cultured, if anything, from the AV graft?
A. Yeah, there was yeast in the AV graft.
Q. Doctor, the fact that there was no VRE found on the graft, does that mean one way or another as to whether or not VRE might have been there given that there was Linezolid already being prescribed?
A. Can you state that again? I'm sorry.
Q. Sure. Would you necessarily expect, even if there had been VRE in the graft at one point, since there had been Linezolid since January 30 had been administered to Irene, would you necessarily have found VRE on the graft at that point?
A. It's hard to say, maybe not.
Q. Why is that?
A. Well, Linezolid may have worked a little bit, may have -- if there was some there. You know, we could certainly have been wrong, and it may not have been there. So it's one of those two possibilities I guess.
Q. Doctor, when a patient is on antibiotics for an extended period of time, does that increase the risk of developing candidemia?
A. It can.
Q. Why is that?
A. It's not clear, but the thinking is that it allows -- by being on antibacterials for a period of time, allows the candida to -- you're changing the environment of the bacteria, and allows the candida to sort of grow more exuberantly than normally, and then it allows it to possibly get into the patient's various systems.
Q. Doctor, on the first page it indicates that -- in the note that you read to us, that there was VRE with the Linezolid administered as of January the 3rd, and then the candida was found on January 25th. Would that be consistent with the possibility that long-term administration of antibiotics was a cause of the candidemia in Irene Carter?
A. I don't know that she was on Linezolid since January the 3rd. I'm sorry. I didn't see that.
Q. Okay. So assume for the moment -- I want you to assume for the moment that she was on antibiotics consistently from January the 3rd all the way to January the 25th when the cultures showed candida in the blood. Would that be consistent with the possibility that being on long-term antibiotics led to the candidemia?
A. It would have been a risk factor.
Q. What was your Problem Number 3, Doctor? Actually, I think you wrote down a recommendation for treating the candidemia?
Q. What was that?
A. Continue fluconazole for now.
Q. What was Problem Number 3?
Q. What did you write under -- what is diverticulitis?
A. Diverticulitis is an abnormal swelling of the blood vessels of the bowel which can -- occasionally it can lead to infection, it can be an infection that's causing that, frequently treated with antibiotics.
Q. Doctor, what did you write underneath diverticulitis?
A. “Received course of treatment at outside hospital.”
Q. So were you recommending any further course of treatment?
A. I was not.
Q. Then the Number 4 problem area?
A. “Question of ventilator associated pneumonia. Gram negative rods from the bronchial alveolar lavage.”
Q. What exactly does that mean?
A. She was intubated, and there was a concern that she might have pneumonia, which is a very difficult thing to diagnose on somebody that's on a ventilator, and she had a lavage from the bronchoscopy that showed some gram negative bacteria that possibly could have been causing her pneumonia.
Q. Did you have any recommendation for the potential pneumonia?
A. Yeah, to add Cipro, Ciprofloxacin, it's an antibiotic.
Q. The next page under, “Attending Physicians” -- I'm sorry, the next line under, “Attending Physicians Note,” says, “I have personally interviewed and examined the patient and reviewed with Dr. Robertson.” Who is Dr. Robertson?
A. He would have been the medical resident that did this, did the writing on the front page and the laboratory notes.
Q. Then at the bottom, is that your handwriting?
Q. For “Risk Level,” you wrote “High?”
Q. And your explanation was what?
A. Vancomycin-Resistant Enterococcus bacteremia, and adult respiratory distress syndrome.
Q. And then you signed this?
MR. AXELROD: Nothing further.
MR. REDDEN: Doctor, again, I'm Charlie Redden. I represent Dr. Nancy Streitmatter.
BY MR. REDDEN:
Q. Ms. Carter died the following day, February the 5th. As a consequence, would it be fair to say, Doctor, that you were unable to definitively determine the source of the bacteremia?
Q. The history of present illness that you were kind enough to read to us, you said before that is not something that you, in fact, prepared, correct?
A. That's correct.
Q. It would appear from your reading of it that this was based upon information that was gleaned from the prior hospitalization at Holy Cross, as well as some information during the first two days at the University of Chicago Hospital, correct?
Q. I take it it would be fair to say you don't know where the resident physician obtained the information about what had happened at Holy Cross, whether it was from another doctor or from review of records?
A. I don't know.
Q. Counsel mentioned to you, I believe, that the culture of the AV graft that had been removed at the University of Chicago showed candida. And assuming that to be correct, that would be consistent with characterizing the AV graft as having been infected, true?
Q. You mentioned with regard to Problem Number 1 and your statement about the source of the bacteremia that the AV graft may have been a possible source. You were thinking that at the time, correct?
Q. If you were to assume and accept that Ms. Irene Carter had an aortic ring abscess at the time of her admission to the University of Chicago Hospital, might that have also been a source for the bacteremia?
Q. And she had a Quinton catheter for dialysis. Might that also have been a competent source for the bacteremia?
Q. There was, I believe, referenced a deep vein thrombosis, a clot. Can those sorts of clots harbor bacteria and be a cause of persistent bacteremia?
A. They can be.
Q. Again, since your involvement with the care of Irene Carter wasn't much beyond this one consultation because she passed away, it would be fair to say you were unable to determine which of those several possibilities were, in fact, the cause of her bacteremia?
A. I agree.
MR. REDDEN: Thank you, Doctor. Those are all the questions I have, sir.
BY MR. AXELROD:
Q. Doctor, when you wrote your report on February 4, 2003, is it likely that you were more familiar with Irene Carter's history than you are now?
Q. And is it correct that it was your conclusion, as written in your report on February 4, 2003, that the likely source of the bacteremia was the AV graft; is that right?
A. I thought it was a potential source, yes.
Q. Well, that's what you thought was the likely source, right?
A. No, I think that I -- well, I think I thought it was a potential source.
Q. Doctor, do you remember giving your deposition that you said you reviewed today?
Q. You agreed to tell the truth at that deposition, right?
A. At that time, I thought it was a likely source, yes.
Q. You don't know whether or not there was an aortic ring abscess on January 3, 2003, do you?
A. I do not.
Q. In fact, that would be unlikely that she would have an aortic ring abscess for over a month and still be alive, wouldn't it?
MR. REDDEN: Object in terms of scope, foundation.
THE WITNESS: I can't tell.
BY MR. AXELROD:
Q. Doctor, according to what the resident wrote, the DVT wasn't found until January the 20th, correct?
A. That's correct. That's correct.
Q. And you're not familiar with how long before the DVT was found Irene Carter was diagnosed with bacteremia, are you?
Q. And you're not familiar with when the graft was inserted, correct?
A. The AV graft?
Q. And you're not familiar with the history of the AV graft insertion, are you?
A. I am not.
Q. And the Quinton catheter, you're not familiar with the history of the insertion, reinsertion of catheters on Irene Carter before your February 4, 2003 consult, correct?
A. I am not.
MR. AXELROD: I have nothing further.
MR. REDDEN: Just for clarification, Doctor.
BY MR. REDDEN:
Q. Had you known as of the day of your consultation, February 4, 2003, that Ms. Carter had an aortic ring abscess, would you have included that in your differential as to possible sources of her bacteremia?
MR. AXELROD: Objection to the form, and it calls for speculation.
MR. PYLMAN: You can answer.
THE WITNESS: I would have included it.
MR. REDDEN: Thank you, Doctor.
MR. AXELROD: Nothing further.
THE VIDEOGRAPHER: This concludes today's deposition. The time 6:13, and we are going off the video record.