Examination 3 - cross exam of surgeon and expert witness in pharmaceuticals products liability case

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CROSS-EXAMINATION

BY MR. BERGER:

Q DR. WATFORD, WE HAVE MET TWICE BEFORE. DO YOU RECALL THAT?

A YES.

Q ONCE IN YOUR IN DECEMBER, AND YOU WERE KIND ENOUGH TO MEET WITH US?

A YES.

Q ONCE IN JANUARY WHEN WE BROUGHT YOU THE ORIGINAL ANGIOGRAM OF MRS. GLOBETTI, AND YOU PLAYED IT IN FRONT OF DRS. JUDELSON AND DR. WATKINS?

A THAT'S RIGHT.

Q WE'VE ALSO HAD A CHANCE TO TALK ON THE TELEPHONE A FEW TIMES, HAVE WE NOT?

A THAT'S CORRECT.

Q SO AS NOT TO KEEP THE JURY IN SUSPENSE, YOU'RE AWARE, ARE YOU NOT, THAT MRS. GLOBETTI HAS A SUBSTANTIALLY IMPROVED EJECTION FRACTION SINCE THE TIME YOU WERE TREATING HER?

A I HAVE BEEN TOLD THAT HER EJECTION FRACTION HAS IMPROVED, YES.

Q AND YOU'RE AWARE THAT THE LAST THREE EJECTION FRACTIONS SHE HAD WERE FORTY-SIX, FORTY-EIGHT AND FORTY-ONE PERCENT AS REFLECTED IN OUR EXHIBITS 401-L, K AND I?

A DO I HAVE THESE? MY RECOLLECTION IS THAT I THINK I WAS TOLD THIS. I'M NOT SURE I SAW THESE REPORTS, BUT I MIGHT HAVE.

LET ME LOOK AT THESE DATES. OKAY. YES.

MR. BERGER: YOUR HONOR, WE OFFER THOSE EXHIBITS INTO EVIDENCE.

THE COURT: ANY OBJECTION?

MS. RELKIN: NO OBJECTION, YOUR HONOR.

THE COURT: THEY WILL BE RECEIVED.

Q DR. WATFORD, LET'S ASSUME THAT YOUR OPINION THAT MRS. GLOBETTI'S ANGIOGRAM WAS DUE TO CORONARY SPASM IS CORRECT.

IT'S ALSO YOUR OPINION THAT THE PLAINTIFFS ARE ON THIN ICE IF THEY ARE TRYING TO SAY PARLODEL CAUSED THAT; ISN'T THAT RIGHT?

MS. RELKIN: OBJECTION, YOUR HONOR.

THE COURT: OVERRULED.

A I HAVE SOME REASON TO - - YOU KNOW, IF I WERE TO COME AS - - I TRIED TO DO THIS AS INDEPENDENTLY AS POSSIBLE. I HAVE SOME REASON OR QUESTIONS THAT PARLODEL DID THIS.

Q SIR, DO YOU REMEMBER AS RECENTLY AS LAST NIGHT WHEN WE WERE ON THE TELEPHONE, MR. SLEDGE, WE WERE TALKING ABOUT THIS?

A YES.

Q AND DO YOU REMEMBER SAYING LAST NIGHT THAT IF THE PLAINTIFFS ARE TRYING TO SAY THAT PARLODEL CAUSES SPASM, THEY'RE ON THIN ICE?

A YES.

Q AND THAT'S YOUR OPINION; CORRECT?

A YES.

Q IN FACT, IT'S YOUR OPINION THAT THE LOGIC OF THIS CASE IS THAT IF A WOMAN TOOK PARLODEL FIVE TIMES PREVIOUSLY WITHOUT A PROBLEM, IT'S VERY UNLIKELY THAT THE SIXTH TIME IT WOULD CAUSE HER TO HAVE A SPASM; ISN'T THAT RIGHT?

A YES, UH-HUH.

Q AND THAT'S ALSO YOUR OPINION TO A REASONABLE DEGREE OF MEDICAL CERTAINTY?

A IT IS.

Q AND YOU HAVE SEEN PEOPLE DEVELOP CORONARY SPASM SUDDENLY FOR NO APPARENT REASON IN YOUR CAREER; CORRECT?

A THAT'S CORRECT, NO REASON WE UNDERSTOOD.

Q THAT'S RELATIVELY COMMON WHEN A PERSON DEVELOPS CORONARY SPASM; ISN'T THAT RIGHT?

A THAT WE DON'T KNOW WHY IT'S CAUSED? YES.THERE ARE TYPES OF SPASM THAT COME FROM THINGS SYNDROME, ARE YOU NOT?

A I AM.

Q AND THAT'S A CONDITION THAT SOMETIMES KNOWN AS DYSAUTONOMIA; CORRECT?

A YES.

Q IT'S REALLY NOT A PROBLEM OF THE HEART, ALTHOUGH IT'S A PART OF THE NAME ASSOCIATED WITH MITRAL VALVE PROLAPSE, BUT IT'S MORE A NERVOUS SYSTEM CONDITION?

A THAT'S CORRECT.

Q AND ONE OF THE CHARACTERISTICS OF THAT CONDITION IS THAT PEOPLE CAN HAVE HIGH ADRENALINE LEVELS; CORRECT?

A THAT'S CORRECT.

Q AND YOU'RE AWARE, SIR, THAT DR. WATKINS BELIEVES THAT MRS. GLOBETTI HAS MITRAL VALVE PROLAPSE SYNDROME; CORRECT?

A I'VE BEEN TOLD THAT. I'VE NOT HEARD IT FROM HIM.

Q AND AS FAR AS YOU KNOW, THAT IS POSSIBLE THAT SHE DOES HAVE THAT; RIGHT?

A WELL, AT THE TIME THAT I SAW HER UP UNTIL THE TIME I SAW HER, I WOULD NOT SAY SHE SUFFERED FROM MITRAL VALVE PROLAPSE SYNDROME.

Q DO YOU REMEMBER YOUR CONVERSATION LAST NIGHT, DR. WATFORD, TELLING MR. SLEDGE AND ME THAT IT WAS POSSIBLE THAT MRS. GLOBETTI DID HAVE MITRAL VALVE PROLAPSE SYNDROME?

A MAYBE I COULD EXPLAIN MYSELF, THE REASON I'M SAYING THAT, IF YOU WOULD ALLOW ME?

THE COURT: SURE.

A THIS MAY BE A TWO OR THREE PARAGRAPH ANSWER.

Q GO AHEAD.

A MITRAL VALVE PROLAPSE IS A CONDITION I DESCRIBED TO YOU. MANY PEOPLE HAVE MITRAL VALVE PROLAPSE YOU CAN HEAR OR SEE ON A ECHO AND THEY DON'T HAVE ANY SYMPTOMS AT ALL.

BUT FOR YEARS, THERE HAVE BEEN A GROUP OF PATIENTS WHO PRESENT TO DOCTORS OR EMERGENCY ROOM WHAT WE CONSIDER CLASSIC SIGNS OF A HEART ATTACK, SEVERE SUBSTERNAL OR BELOW YOUR CHEST OR IN YOUR CHEST PAIN, MAY OR MAY NOT RADIATE TO THE JAW OR THE ARM, SENSATION THAT THEY ARE SHORT OF THE BREATH, CAN'T GET A DEEP BREATH, SENSATIONS OF PALPITATIONS OR SKIPPED BEATS IN THE HEART.

MANY OF THESE PEOPLE ARE PROFOUNDLY FATIGUED. SOME OF THESE PATIENTS ALSO HAVE ASSOCIATED GI COMPLAINTS ABOUT THEY MAY FIND WHEN THEY GET NERVOUS THEY SUDDENLY HAVE TO GO TO THE BATHROOM. THAT'S A VERY SMALL PERCENTAGE OF PEOPLE IN THAT SYNDROME. MOST PEOPLE HAVE THE CONSTELLATION SYMPTOMS I JUST MENTIONED.

NOW, YEARS AGO WHEN THEY STARTED DOING ECHOS ON PATIENTS, THEY SAW THAT MANY OF THESE PEOPLE ALSO HAD PROLAPSE OF MITRAL VALVE. AND SOMEONE SAID MAYBE THESE ARE RELATED, AND ALL THE SUDDEN PEOPLE STARTED SAYING, YES, THEY ARE RELATED.

AND EARLY ON PEOPLE SAID, YOU KNOW, THIS IS A GREAT THING. WE'VE GOT THIS NEW ECHO TEST, AND WE CAN SEE EARLY PROBLEMS IN VALVES. THESE PEOPLE ARE LATER GOING TO HAVE VALVES, YOU KNOW, HAVE PROBLEMS. THIS IS WONDERFUL. WE CAN SAVE THEM AND FIX THEM BEFORE THEY HAVE TROUBLE.

SO A LOT OF PEOPLE HAVE BEEN TOLD THINGS OVER A GENERATION OR TWO THAT HAVE LATER NOT REALLY HELD UP TO FURTHER OBSERVATION AND TESTING.

ONE INTERESTING AND CONFOUNDING THING IS THAT PATIENTS WHO HAVE THAT SYNDROME FREQUENTLY HAVE VERY SEVERE AND DEBILITATING SYMPTOMS BUT NOTHING BAD EVER HAPPENS TO THEM. THEY MAY COME TO THE HOSPITAL AND HAVE A ARTERIOGRAM. THE ARTERIES LOOK NORMAL. THEY SHOW NO DAMAGE TO THE HEART.

SOMETIMES THESE PATIENTS HAVE SEEN SO MANY DOCTORS AND THEY CAN'T REALLY PUT THEIR FINGER ON IT, BUT THEY FINALLY LABEL THEMSELVES AS, YOU KNOW, MAYBE THEY'RE MAKING IT UP OR THEY'RE COOKY OR SOMETHING IS WRONG WITH THEM.

AND MANY OF THE PATIENTS I SEE WITH THIS SYNDROME HAVE BEEN TOLD THINGS LIKE THAT, AND BECAUSE THEY HAVE SYMPTOMS THAT ARE VERY DIFFICULT TO EXPLAIN AND IT DOESN'T EVER SEEM TO CAUSE PROBLEMS — THEY DON'T CAUSE DAMAGE AS FAR AS A THREAT, BUT THEY CLEARLY CAUSE A PROBLEM WITH THEIR LIFE.

GIVEN THAT BACKGROUND, FURTHER RESEARCH HAS COME OUT IN MITRAL VALVE PROLAPSE, AND THERE'S A NEW SCHOOL OF THOUGHT THAT'S BEEN AROUND FOR SEVERAL YEARS. AND THAT IS THAT THEIR REALLY IS NOTHING ABOUT THE MITRAL VALVE THAT HAS ANYTHING TO DO WITH THESE SYMPTOMS. JUST BECAUSE THESE PATIENTS WERE SEEN TO HAVE MITRAL VALVE PROLAPSE, SOME PEOPLE HAVE WONDERED, WELL, WHAT IF WE ASKED HOW MANY OF THEM HAD BLUE CARS, AND WE WOULD NOW SAY THEY HAVE THESE SYMPTOMS BECAUSE, YOU KNOW, SEVENTY PERCENT OF THEM HAVE BLUE CARS.

AND THAT LED TO MORE RESEARCH THAT HAS SHOWN IN MOST OF THESE PATIENTS, IF THEY HAVE SIMPLE MITRAL VALVE PROLAPSE, AND BY THAT I MEAN THEY DON'T HAVE SOMETHING STRUCTURALLY WRONG WITH THE VALVE THAT PUTS THEM IN A SEPARATE CATEGORY, IF THEY HAVE A MORE SIMPLIFIED FORM OF MITRAL VALVE PROLAPSE AND ARE HAVING THESE SYMPTOMS, IT'S LED TO RESEARCH THAT SUGGESTS THAT MOST OF THEIR SYMPTOMS ARE FROM INAPPROPRIATELY HIGH LEVELS OF ADRENALINE IN THEIR BODY.

EVIDENCE THAT SUPPORTS THIS, NOT ONLY HAS IT BEEN SEEN THAT THERE ARE HIGHER LEVELS OF CIRCULATING ADRENALINE, BUT ALSO TREATMENT TO LOWER THE EFFECTS OF THE ADRENALINE AND LOW YOUR OWN ADRENALINE LEVELS SEEM TO IMPROVE THE SYMPTOMS.

SO THAT IF YOU CAN GIVE A CLASS OF MEDICATIONS WE REFERRED TO EARLIER CALLED BETA BLOCKERS, THEY BLOCK SOME OF THE RECEPTORS FOR ADRENALINE, IF YOU HAVE PEOPLE AVOID CAFFEINE AND OTHER STIMULANTS TO ADRENALINE, IF YOU HAVE THEM EXERCISE WITH AEROBIC EXERCISE FREQUENTLY AND A GOOD LEVEL OF EXERCISE, IT NOT ONLY BURNS UP THE EXTRA ADRENALINE THAT'S THERE, BUT IT ALSO OVER A FEW MONTHS HAS A FEEDBACK TO MAKE THE BODY PRODUCE LESS ADRENALINE. AND PATIENTS HAVE DRAMATIC IMPROVEMENT IN THEIR SYMPTOMS.

FROM THAT STANDPOINT, I ALWAYS TELL MY PATIENTS, I'M SORRY THAT THE TERM MITRAL VALVE PROLAPSE STILL IS AROUND BECAUSE IT IMPLIES SUDDENLY IN THE BACK OF YOUR MIND THAT THERE'S REALLY SOMETHING WRONG WITH YOUR HEART, WHEREAS IN MY OPINION BASED ON MY TRAINING AND MY EXPERIENCE IS THAT THE HEART IS AN INNOCENT BYSTANDER, THAT THE PALPITATIONS ARE FROM EXTRA ADRENALINE SURGES. THE SHORTNESS OF BREATH IS ACTUALLY A SENSATION IN YOUR CHEST, BECAUSE YOUR ESOPHAGUS WHICH IS YOUR FEEDING TUBE TO YOUR MOUTH TO YOUR STOMACH ACTUALLY CAN TIGHTEN AND SPASM, PERHAPS NOT TOTALLY BUT JUST TIGHT IN A WAY THAT GIVES YOU CHEST PAIN, SINCE IT'S FED BY THE SAME NERVE THAT FEEDS THE HEART, IT GOES TO A COMMON PLACE IN YOUR BRAIN.

YOUR BRAIN THINKS, MY GOODNESS, THIS IS MY HEART. WELL, IN FACT, NONE OF US FEEL HEART PAIN. WE FEEL CHEST PAIN. I WISH GOD HAD ALLOWED US TO AT LEAST FEEL ESOPHAGUS PAIN OR TRACHEA PAIN OR HEART PAIN, BUT WE DON'T.

SO THE SYMPTOMS CAN BE VERY SIMILAR TO HEART DAMAGE OR A PROBLEM WITH YOUR HEART, AND BECAUSE THE HEART IS PALPATING BECAUSE IT'S OVER STIMULATED, MANY PEOPLE LOGICALLY CONCLUDE THAT THIS IS A HEART PROBLEM.

BUT, IN FACT, I THINK MOST OF EVIDENCE SUGGESTS THAT THE ESOPHAGUS IS AN INNOCENT BYSTANDER, THE TRACHEA IS, THE HEART IS, THE GI TRACT IS BECAUSE —

Q DR. WATFORD, I HATE TO, BUT — GO BACK TO MY QUESTION, PLEASE, AND LET'S HAVE AN ANSWER. THANK YOU.

(RECORD READ.)

A IF I REMEMBER CORRECTLY, WE WERE TALKING ABOUT NOW VERSUS WHEN I SAW HER.

Q TALKING ABOUT NOW.

A YES. I THINK THAT'S POSSIBLE.

Q AND THE COMPLAINTS THAT ARE TYPICAL OF MITRAL VALVE PROLAPSE SYNDROME, WHICH YOU'VE EXPLAINED TO US, ARE SHORTNESS OF BREATH, PALPITATIONS AND FATIGUE; CORRECT?

A CORRECT.

Q AND MITRAL VALVE PROLAPSE SYNDROME ASSOCIATED, I THINK AS YOU SAID, WITH INAPPROPRIATELY HIGH

Q AND THAT'S USUALLY ABBREVIATED L-A-D; RIGHT?

A CORRECT.

Q AND THIS ONE COMING DOWN WAS THE CIRCUMFLEX, AND I'LL JUST PUT ”“C‘’ FOR THAT; IS THAT FAIR?

A THAT'S FAIR.

Q IT'S YOUR TESTIMONY TODAY, I THINK, THAT YOU DO NOT KNOW WHAT THAT IS?

A THAT'S CORRECT.

Q YOU CAN GO BACK TO YOUR SEAT.

MR. BERGER: FOR THE RECORD, THE ”“THAT‘’ THAT WE REFERRED TO IN THE LAST QUESTION WAS A GREEN CIRCLE AROUND THIS LITTLE APPENDAGE ON THE INFERIOR SIDE OF LEFT MAIN; IS THAT RIGHT?

A THAT'S CORRECT.

Q NOW, WHEN WE HAD A MEETING IN YOUR OFFICE ON JANUARY 20TH, 2 001, YOU UNDERSTOOD THAT THE PURPOSE OF THE MEETING WAS TO ALLOW TWO CARDIOLOGISTS WHO ARE EXPERTS FOR US IN THIS CASE TO SEE YOU PERSONALLY GO THROUGH THE ANGIOGRAM THAT YOU DID AND HEAR WHAT YOU HAD TO SAY ABOUT IT.

A THAT'S CORRECT.

Q YOU SET UP THE EQUIPMENT YOURSELF, THE ANGIOGRAM READER?

A I DID.

Q YOU OPERATED IT; CORRECT?

A CORRECT.

Q THIS WAS THE FIRST OPPORTUNITY THAT YOU HAD HAD TO LOOK AT THE ORIGINAL ANGIOGRAM SINCE 1993; IS THAT RIGHT?

A THAT'S RIGHT.

Q BY THE WAY, IT'S TRUE, ISN'T IT, DR. WATFORD, THAT THERE'S A LOT OF SUBJECTIVITY IN THE INTERPRETATION OF ANGIOGRAMS?

A THERE'S SUBJECTIVITY IN THE INTERPRETATION AND DEGREE OF STENOSIS. AND WHEN PEOPLE SAY HOW NARROW IS THAT VESSEL, I THINK THERE ARE PEOPLE WHO SAY, YES, THERE'S SUBJECTIVITY THERE. THERE'S LESS SUBJECTIVITY ABOUT OTHER THINGS ABOUT IT.

Q AND WHEN YOU PLAYED THE ANGIOGRAM FOR DR. JUDELSON, DR. WATKINS, YOU RECOGNIZED WHAT YOU HAD CALLED ON YOUR REPORT THE SHELF OF DYE.

A THAT'S CORRECT.

Q THE REASON YOU WROTE THAT INTO YOUR REPORT IS BECAUSE YOU RECOGNIZE THAT THAT WAS AN ABNORMALITY; CORRECT?

A CORRECT.

Q IN FACT, I THINK YOU TESTIFIED ON DIRECT THAT YOU HAD NEVER SEEN SOMETHING LIKE THAT BEFORE.

A THAT'S CORRECT.

Q AND YOUR REPORT SUGGESTED THAT PERHAPS THAT WAS AN OBTUSE BRANCH VESSEL; CORRECT?

A IT'S ONE OF THINGS I SUGGESTED, CORRECT.

Q BUT WHEN YOU REVIEWED THE ANGIOGRAM WITH DRS. WATKINS AND JUDELSON ON JANUARY 2 0TH, DIDN'T YOU SAY THAT NO, THAT'S NOT A BRANCH VESSEL?

A I DON'T REMEMBER IF I SAID THAT, BUT MY OPINION IS IT DOESN'T LOOK LIKE A FULL VESSEL.

Q YOU DON'T RECALL SAYING THAT IT WASN'T A BRANCH VESSEL?

A I MAY HAVE SAID SOMETHING TO THAT EFFECT. I GUESS RIGHT NOW, MY TESTIMONY WOULD BE IT DOESN'T LOOK LIKE A FULL VESSEL THAT WHEN YOU PUT AT OTHER ANGLES, YOU SEE THE REST OF THE VESSEL COMING OUT.

Q YOU COULD NOT FIND WHERE THAT ALLEGED VESSEL WAS GOING; IS THAT RIGHT?

A THAT IS CORRECT.

Q AND THAT'S WHY A CARDIOLOGIST TAKES DIFFERENT VIEWS; CORRECT?

A RIGHT.

Q DO YOU REMEMBER IN THAT MEETING OF JANUARY 20TH, 2001, WHEN YOU WERE ASKED IS IT POSSIBLE THAT THAT'S A RUPTURED PLAQUE AND YOU SAID YES?

A IT IS POSSIBLE.

Q AND THAT'S STILL YOUR OPINION?

A IT'S POSSIBLE, BUT THAT'S NOT MY JUDGMENT OF WHAT IT IS.

Q BUT DIFFERENT CARDIOLOGISTS CAN HAVE DIFFERENT JUDGMENTS; CORRECT?

A I'M CERTAIN THAT'S TRUE.

Q DID YOU, FOR EXAMPLE — OH, LET ME WITHDRAW THAT.

I WOULD LIKE TO PUT THE ANGIOGRAM UP ON THE PROJECTOR IF WE CAN. AND LET'S JUST STOP HERE FOR A SECOND. ON THIS VERSION OF THE ANGIOGRAM, WE'VE GOT A COUNTER THAT WILL LET US REFER BACK TO THE PARTICULAR AREAS LATER IF WE NEED TO. DO YOU SEE THAT?

A YES.

Q LET'S GO FORWARD AGAIN. LET'S JUST STOP THERE FOR A SECOND. THIS IS APPROXIMATELY WHAT YOU FIRST SHOWED THE JURY WHEN YOU STARTED TO SHOW BEFORE; IS THAT RIGHT?

A MAYBE A FEW FRAMES DOWNSTREAM WE'LL SEE SOME CONTRAST IN THE AORTA.

Q I JUST WANT TO NOTE THAT THIS — LET'S SEE IF THIS WORKS. WE'VE GOT A CROSS THERE INSTEAD OF POINTER. THAT WILL BE A POINTER. CAN

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