Nursing Home Examination 3 - Direct and Cross of Internist - Part 3

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CROSS-EXAMINATION

BY MR. POWER:
Q. Hi, Doctor. I think you've told us that you do not practice medicine and haven't done so since 1995 as an internal medicine physician, correct?
A. Yes.
Q. And, in fact, if we went to the ten years before 1995 and asked you how many times you had seen patients in a nursing home on an annual basis, you would have to tell me it would be maybe as little as two, correct?
A. Annual?
Q. Yeah.
A. I saw my patients once a month, and I generally ave: ied about two to three pat nts at some time, so I was - so that would be two times 12 would be 24.
Q. Now, you're telling me for the ten years you were actually practicing internal medicine and saw patients in a nursing home -
A. I practiced much more than ten years, Counsel.
Q. Between 19 - if you let me finish.' When you were seeing patients in a nursing home, you only saw patients in the nursing home for approximately a ten-year period between 1984 and 1994, correct?
THE WITNESS: I started practice in 1978 -
MR. POWER: Objection, Judge. Not responsive. Move to strike.
THE WITNESS: Well, I saw patients in nursing homes throughout my entire practicing career.
BY MR. POWER:
Q. So it's your testimony today you saw patients in a nursing home before 1994, correct?
A. Before 1984.
Q. I'm sorryBefore 1984, correct?
A. You're correct, yes.
Q. You became an internist in when?
A. In 1976.
Q. And' r the first few years you?re building a practice and didn't have any geriatric patients in that practice, true?
A. For the first two years I was doing my endocrine fellowship. I did not start seeing patients privately until ‘78.
Q. Then for the first five years thereafter, you really didn't see any patients in a nursing home, true?
A. I saw patients in a nursing home. I can't give you the exact year I had my first patient in a nursing home that I followed. If you can produce the records of the nursing home where I had patients, I can give you the -
MR. POWER: Objection. Move to strike, your Honor, as nonresponsive.
THE COURT: It will be stricken as nonresponsive. That jury will disregard that portion of the witness's answer.
BY MR. POWER:
Q. Sir, did you ever give an answer to the contrary under oath as to whether you saw patients in nursing homes between 1978 and 1983 or 1984?
MR. SHAPIRO: Objection.
THE COURT: Overruled.
THE WITN??: I cannot say with cert??ty when I started seeing patients in nursing home - in nursing homes after I started practice. BY MR. POWER:
Q. Sir, isn't it true the first five years that you were in practice, when you started practicing in 1978, you didn't see patients in nursing homes?
A. I don't know that.
Q. Well, let me refresh your recollection.
A. Refresh my recollection. Because if I said that during the deposition, I wouldn't know it then either.
Q. So you're just guessing when you say it in your deposition?
A. Probably.
Q. Okay. So -
A. Just trying to give you a reasonable date when I started seeing nursing home patients.
Q. When you were under oath sworn to tell the truth, you started guessing as to when things occurred; is that true?
A. I told the truth as best to my recollection.
Q. And to the best of your recollection, you saw no patients in a nursing home between ‘78 and nineteen eighty - well for the first five years,??ill 1983, true?
A. What I can truthfully respond -
MR. POWER: Objection, Judge, move to strike.
THE WITNESS: - I'm not certain when I started seeing patients in the nursing homes. BY MR. POWER:
Q. Sir, didn't you give the following answers to the following questions.
MR. POWER: Page and line 85.
MR. SHAPIRO: Can I give him a copy?
MR. POWER: Judge, I'm really not interested in refreshing his recollection. I want to ask him the question.
THE COURT: You may ask the question.
MR. POWER: Thank-you.
MR. SHAPIRO: Judge, may I give the witness?
THE COURT: No. BY MR. POWER:
Q. To put it in context, I have to step back.
“Question: Then before that, at what frequency did you see patients in a nursing home. We are now back to 1984 and earlier.
“Answer: The first five years that I was in practice, and' started in practice in 19,I didn't see patients in nursing homes.Once I developed some very close bonds with families, I started picking up patients in nursing homes, generally after they were discharged from the hospital for an acute episode, and they could no longer go back to home care.”
Didn't you give that answer to that question on May 10 - excuse me, May 16, 2000 while you were under oath?
MR. SHAPIRO: Objection.
THE COURT: Sustained. It's not impeaching. The jury will disregard those questions and answers given on the deposition. They will be stricken. BY MR. POWER:
Q. Would you like to see your deposition to see if it would refresh your recollection as to whether you said that on May 16, 2000?
A. More than happy to.
Q. Okay.
A. I'm certain if that's what I said in the deposition, that's what I said.
Q. But I don't want you to guess. I don't want you to -
THE COURT: Hold it. Counsel's remarks will be stricken. It' improper. Jury will disr??ard counsel's
remarks.
BY MR. POWER:
Q. Let me show you a copy of your deposition. I direct you to page 85, starting at line 17. I'm sorry, starting at line 14. I apologize.
A. In the first five years I was in practice -
THE COURT: Read it to yourself.
THE WITNESS: Okay. Approximate. It was an approximate number. BY MR. POWER:
Q. Okay. And theres nothing that you've learned since then to change that approximate number, correct?
A. Correct.
Q. Now, after 1995 you didnt see any patients in nursing homes, correct?
A. Yes.
Q. So you saw patients in nursing homes between 1984 and 1995 or late ‘94 whenever you stopped practicing internal medicine and seeing patients in nursing homes, true?
A. Approximately true.
Q. Now, isnt it true, sir, that you have no idea how many times you saw patients in a nursing home as a primary care?? sician in the year 1995?
A. Yes.
Q. It could possibly be less than two, true?
A. Yes.
Q. And in 1994 you have no recollection of how many times out of the year you actually went to see a patient in anursing home, true?
A. True.
Q. In fact, all you can say is that you probably went to a nursing home during 1994 between five and ten times the entire year, true?
A. I couldnt even say that with probable. I dont know.
Q. In fact, it could be less than five, right?
A. Yes.
Q. Now, you dont specialize in geriatric medicine, true?
A. True.
Q. Youve never served on a staff - never served as a staff physician at a nursing home, true?
A. True.
Q. Since were talking about your area of medicine, endocrinology - endocrinology I think you told us was a subspecialty of internal medicine?
A. Yes.
Q. Internal medicine has a separate specialty, correct?
A. Internal medicine itself is a separate specialty.
Q. And along with each area of specialty, there are board certification processes that go along with that?
A. Yes.
Q. And, sir, a board certification process is something that people who receive their degree in that area of specialty go on to take additional testing to show their peers within that specialty that they have the added qualifications necessary to be called board certified within that particular area, true?
A. Well, just that they've taken the test.
Q. Well, if you take the test and fail, you wouldnt be board certified, right?
A. You would be board eligible whether you take the test or not.
Q. But if you take the test and prove to them that you have the qualifications to be called board certified, you are then called board certified, true?
A. If you take the test and pass the test, you're board certifie
Q. Thank-you.
In order to become board certified in
endocrinology, you first have to become board certified in internal medicine, true?
A. True.
Q. You're not board certified in endocrinology, are you?
A. Never took the test.
Q. So you're not board certified in endocrinology?
A. Right. True.
Q. In fact, you're not even board eligible in endocrinology because you haven't become board certified in internal medicine, true?
A. True.
Q. Okay. So even to be considered board certified in endocrinology, you would have to take your internal medicine boards which you have never done?
A. True.
Q. So you're not recognized within the area of endocrinology as a specialist that meets the qualifications of board certified endocrinologist, true?
A. I'm recognized as an endocrinologist.
Q. Fai: nough.
Now, you're not on the active staff of any hospital, correct?
A. No, I'm on the emeritus staff.
Q. An emeritus staff is privileges that they extend to physicians who had previously been active but want affiliation with the hospital, right?
A. Yes.
Q. You don't go to hospitals, you don't treat patients, correct?
A. True.
Q. Now, Doctor, as a conceptual matter, you don't have a problem with internal medicine physicians treating insulin dependent diabetics, true?
A. Correct.
Q. You agree -
A. Some do an outstanding job.
Q. I'm sorry?
A. Some do an outstanding job treating diabetes.
Q. So conceptually the fact that Mr. Carter was managed by an internist as opposed to endocrinologist
isnt something you think that he was automatically mismanaged?
A. Correct. Emphatically correct.
Q. I'm rry?
A. Emphatic on that.
Q. In fact, you think it's appropriate for board certified internal medicine physicians to follow Mr. Carter for the treatment of diabetes, assuming it's done appropriately, true?
A. Yes.
Q. Now, Doctor, very briefly we talked about the time for your affiliation with this case. I think you said you charge $3,000 to testify. In fact, it's $3,000 whether it's an hour or two hours or the whole day, true?
A. Correct.
Q. And you gave two separate depositions in this case, right?
A. Yes.
Q. In addition, you've read some records, right?
A. Yes.
Q. Now, Doctor, you're telling us that your affiliation with Mr. Shapiro played no role in your review of the documents and coming to an objective opinion; is that true?
A. Yes.
Q. So you wanted to give my client, Dr. Azaran, a fair and objec we review of the material??o determine whether, in your opinion, he complied with or deviated from the standard of care, true?
A. Yes.
Q. And before offering any opinions either verbally or in writing that he complied with or deviated from the standard of care, you, in fact, reviewed all of the materials that were sent to you by Mr. Shapiro's office, true?
A. Yes.
Q. And, in fact, you wrote a letter to
Mr. Shapiro and told him exactly what you reviewed. I'm not going to ask you to try to remember it. I'll just go and look at it. You reviewed the Glenwood Terrace Nursing Home records, true?
A. (Nonverbal response.)
Q. True?
A. True.
Q. You reviewed the St. James Hospital records, true?
A. True.
Q. You then reviewed the Ingalls Memorial Hospital records, right?
A. True.
Q. You Iso reviewed the Imperial rsing Home records, true?
A. True.
Q. And to be fair and partial to my client, I think you even mentioned that you made an extensive review of those materials; isn't that true?
A. True.
Q. Now, sir, after your extensive review of these materials, you came to certain opinions, true?
A. True.
THE COURT: The record will reflect that counsel has stacked up some folders and notebooks that he has then just placed his hand upon that, but there has been no testimony from this witness with regard to what those are. The jury will disregard any showing by counsel of what he wishes to portray to the jury. It's improper. BY MR. POWER:
Q. Sir, let me do it again with you, then.
THE COURT: Witness has testified what he's reviewed, Counsel. Put your props away.
MR. POWER: I'm sorry?
THE COURT: Put your props away. BY MR. POWER:
Q. Isn't it true, sir, that after reviewing all of these docur??ts you - at $350 an hour ou had charged a total of less than $700, less than two hours time, to come to your opinion?
A. I have to review my bill. But if that is what my bill reflects, that's what I billed for. I don't overcharge. I only bill for the time that I spent.
Q. And it's your best estimate you spent less than two hours?
A. Whatever my bill is exactly what I - the time that I spent. Been in practice for 25 years. I can review a chart.
MR. POWER: Objection. Move to strike. Nonresponsive.
THE COURT: The witness's answer will be stricken. There is no question pending. The jury will disregard the witness's response. BY MR. POWER:
Q. At the time back in May of 1998 you would agree that up until that time you had billed Mr. Shapiro a total of less than $700, true?
A. Again, I have to review. That was before the depositions, too.
Q. Yes, sir, absolutely.
A. Sure. Yeah.
Q. Wou?? your deposition testimony nd your comments about what you had billed him up until that time assist you in refreshing your recollection?
A. Let me look at the bill.
Q. Well, sir, that unfortunately has never been sent to me, so I -
THE COURT: Counsel's remark will be stricken. The jury will disregard that remark.
BY MR. POWER:
Q. I do not have your bill, sir. I'd like to show you your deposition testimony starting at page 6 and ask you to review it to yourself, from page 6 to page 7. And that's from session one which I believe is 1998.
Does that refresh your recollection as to what you had charged up until that time?
A. Which says I charged 350 an hour on the two pages you asked me to read.
Q. I'm sorry. Go to page 8. I apologize.
A. Again, that was a guesstimate then. I know a more recent bill which reflects more review of the records is much larger than that, reflecting the additional time.
Q. At that point you said that it was certainly safe - safel less than a thousand, rig??
A. If you read my response, it was a guesstimate.
Q. Let me show you again, sir. If you just look at page 8 starting at line 11.
A. I say, I'd say less than 700.
Q. You said it was safely less than a thousand, but probably less than 700, fair?
A. Safely less than a thousand but probably less than 700, because I did not know.
Q. Okay. So not more than three hours but maybe less than two?
A. Not even to that definitively without a copy of the bill.
Q. Well, sir, you would agree that it would be important to determine whether a patient is a type one or type two diabetic accurately for purposes of classifying them and treating them, true?
A. I said important to determine if they're insulin dependent or not.
Q. Do you know the difference between type one and type two diabetic?
A. Yes.
Q. You would define a type one diabetic as an insulin dependent diabetic, true?
A. Tru??
Q. You would define a type two diabetic as someone who is not insulin dependent, correct?
A. Wrong.
Q. Have you ever given an answer under oath to the contrary?
A. I may have differentiated between insulin dependent and insulin requiring. Many type twos become insulin dependent and/or insulin requiring. It's a semantic term. So I may have used “insulin requiring” under oath.
Q. Well, sir, a type two diabetic is not an insulin dependent diabetic, true?
A. That - that statement is wrong. A type two can be insulin dependent as I stated - as I explained yesterday, because eventually the pancreas burns out entirely.
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Overruled. BY MR. POWER:
Q. I'm sorry. The last question and answer, I'm not sure if I asked you correctly. A type two diabetic is not insulin dependent, true?
A. And??e answer remains the same false.
Q. Okay.
A. I'm not going to get into a semantic game when clearly type twos, half of them become insulin requiring, many of whom eventually become insulin dependent. If that was not clear in the deposition I gave in May of this year, so be it.
Q. Do you remember giving an answer to the following questions in May of this year under oath on page 134. Question -
MR. SHAPIRO: Excuse me, what line, Counsel?
MR. POWER: Starting at line 6 going to line 19. Actually, starting at line 5. BY MR. POWER:
Q. “Question: What is type one?
“Type one is an insulin dependent - is
insulin dependent diabetes also referred to as juvenile onset diabetes, but we prefer type one. There's less confusion when we try to categorize it based on the dependence of insulin.
“Question: What is type two? “Answer: Type two is a diabetic who is not insulin dependent, maybe insulin requiring, but they're not dependent in that they don't die when they're denied insulin. The gars may go way up, but?? are usually nonketotic and they don't die. So they're not dependent on insulin for life, but it's certainly required for controlled diabetes.”
Did you give that answer to that question -
A. Yes.
Q. - in May of -
A. Yes.
Q. May 2000?
A. Answer is totally accurate. Perfectly accurate answer.
Q. Mr. Carter is an insulin dependent diabetic, in your opinion, correct?
A. Yes. He's a type two that is clearly insulin dependent. That's why he was nonketotic. Why it was not diabetic ketoacidosis.
MR. POWER: Objection. Move to strike.
THE WITNESS: I'm answering to the question.
THE COURT: Overruled.
THE WITNESS: Thank-you. BY MR. POWER:
Q. Now, in your opinion throughout the entire time you reviewed these records for this time period from the time he was admitted to Glenwood until the time that he passe?? he required 22 units of?? ulin N as a baseline because of his diabetes, true?
A. Well, he required a basal dose of insulin. I don't know if it was always 22 units per se, but he was on a basal insulin.
Q. You would agree, then, that the baseline dose of insulin would change or alter depending on his glucose readings when they checked them, correct?
A. Yes.
Q. It could go up from 22 units, it could go down from 22 units -
A. Yes.
Q. - true?
In fact, when you reviewed this, you saw his insulin base levels went as low as 8 units at the Imperial Nursing Home records subsequent to this time frame, right?
A. Yes, sir.
Q. Okay. And it was appropriate to adjust the baseline dose of insulin down as his eating needs dropped or his sugar processing needs changed, correct?
A. Yes.
Q. But you would agree, ultimately, it was never your opinion and it is not your opinion today that Mr. Carter is type one diabetic, true?
A. Well, he's not a type one.
Q. Okay.
A. He did not have an immunologic destruction of his pancreas, but he was a type one in behavior in that he ultimately burned out his pancreas and had no endogenous insulin or very little endogenous or insulin coming from within his own body.
Q. Now, when you reviewed all these materials other than your three-week period, it's your opinion - I'm sorry, other than the three-week period and the January 25 through January 23 or January 31 time frame that we talked about yesterday, you would agree that on the baseline dose of insulin and the various times he was on BGM monitoring coverage, he was generally a well controlled diabetic, true?
A. Absolutely wrong. Absolutely untrue.
Q. Okay.
A. His blood sugars at Ingalls prior to his admission to Imperial, the February 1 admission, his blood sugars were consistently out of control even on the 2 0 units.
Q. Fair enough. If we - if we take away, then, the Imperial Nursing Home records from February 1 to many other th?? s other than just that - ?? -
Q. Fair enough.
A. That facet.
Q. That was one of the facets?
A. That was one of the facets.
Q. In order to do that, you needed to look at the - in fact, you did look at the limited Terrace Nursing Home records, correct?
A. Correct.
Q. You looked at the - and that went from February ‘94 all the way through December ‘94, correct?
A. Again, I hope you're giving me the right dates with that.
Q. Well, you know he was admitted to St. James in December of ‘94 when he fell, and he had the stroke and he stayed there until he went to the Imperial in January of 1995, right?
A. I've not reviewed those records recently, prior to this court date. So, again, I assume you're giving me the correct dates.
Q. I'd be more than happy to show you the chart, if you would like to.
A. Again, if you're not lying to me, you don't have to show me the chart.
Q. And??e of the things you neede??o find out here was whether he was under control to find out if his insulin needs were being met based on the 22 units so that you can formulate an opinion that 22 units gave him proper coverage, true?
A. That's false, because I did not need that data to know that on the February 1 admission to the Imperial and subsequent discharge on the 20th that he went out of control.
Q. Okay.
A. I actually did not need that record to make that determination. I reviewed that record but I did not need that record to make that determination.
Q. And in reviewing this record, you learned that he was generally well controlled on his 22 units with BGM coverage as needed, correct?
A. If that's the dose he was on during that stay, correct.
Q. And then you looked at the Imperial and Ingalls records up to the February 1 admission and you've already told us you think he's out of control at Ingalls from January 13 - excuse me, January 18 all the way to February 1?
A. Well, with the exception of one day, the 24th of January.
Q. So when he was on the 22 units on the date of admission to Ingalls on January 19 and was given BGM coverage on January 20, is it your testimony that this man was out of control all the way up to the time of discharge?
A. Yes, by abnormal blood sugars. They were clearly documented in the record. They were consistently universally abnormal.
Q. Now, sir, generally when you put someone on BGM with sliding scale insulin, the numbers start at 200 and then go up to 250, 3 and maybe as high as 4, true?
A. Repeat the question.
Q. Sure. You are aware that it is standard practice in providing Humulin R with coverage to start the Humulin R when blood sugars reach 200, then you give a certain number of units, 250 a certain number of units, three -
A. That is absolutely false, and that's one of the tragedies of diabetes care in this country.
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Answer will be stricken. Everything after “absolutely false” will be stricken as nonresponsive The jury will disregard t?? t?? portion of the witness's answer.
Sir, will you please just answer the question that's asked.
THE WITNESS: False. Absolutely false. BY MR. POWER:
Q. When you reviewed the St. James records and the Glenwood Terrace Nursing records and the Ingalls records before and after February 20, isn't it true that every single time that he was placed on BGM coverage the coverage started when the blood sugars elevated above 200?
A. Yes.
Q. Okay. And that was true for every doctor that treated him during the time frame, put him on BGM with coverage starting at 200, true?
A. In addition to his basal dose of insulin, yes.
Q. Now, Doctor, I'm confused. Is it your opinion that the fasting blood sugars stop when you reach a level of 110 for within the range of normal?
A. It's not my opinion. It's on the laboratory.
Q. Okay.
A. Of every hospital that does blood sugar, 110 is abnormal, above 110 is abnormal.
Q. And??s your opinion, then, th?? anything over 140 random is abnormal?
A. Again, it's not my opinion. It's - that's definition.
Q. Okay.
A. Of abnormal glucose. Any random of 140 or higher is by definition abnormal glucose metabolism, by definition. It's not my opinion.
Q. Didn't you tell us yesterday that you would consider Mr. Carter normal if he had minimum - or excuse me, fasting glucoses of less than 140?
A. No. What I said -
Q. Okay.
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Everything after “no” will be stricken as nonresponsive. The jury will disregard everything after “no.” BY MR. POWER:
Q. Didn't you tell us yesterday on direct that anything on the random scale above 180 would be the first time you would be concerned for Mr. Carter?
A. I told you that the action level, where you take action, standard of care recognized level -
MR. POWEF?? Objection. Move to stri
THE COURT: Overruled. That is responsive.
THE WITNESS: The action level, the standard of care is you take action if the fasting is 140 or higher. Something must be done. Not that the blood sugar's abnormal, that goes without saying, but the action level where you take action to correct an abnormal state is at 140. BY MR. POWER:
Q. So it's your opinion in Mr. Carter's situation the first time action is needed for him for a fasting sugar is if it's higher than 140, true?
A. 140 or higher, true.
Q. Fair enough. I don't want to quibble over one number.
A. Well, it's important. It's a definition. It's not my opinion. It's the definition.
Q. Fair enough. And it's your opinion that action is required, then, when the random sugars are 180 or higher, true?
A. True.
Q. Now, you agree with me that on this lab value that you mentioned on February 2 it doesn't say fasting blood sugar value 70 to 101, true?
A. It J??a fasting. It's 5:30 am.
MR. POWER: Objection move to strike as nonresponsive.
THE COURT: That will be stricken as nonresponsive. The jury will disregard that answer. BY MR. POWER:
Q. The lab values, the reference ranging 70 dash 101 doesn't say fasting, true?
A. True.
Q. Okay. There's no order in the chart on February 1 that Mr. Carter should be withheld sustenance at 8, 9 or 10 at night, true?
A. True.
Q. The labs were drawn at 5:30, true?
A. True.
Q. You don't know if he was given a snack at night, true?
A. True.
Q. If you wanted a true fasting blood sugar, it would be important to tell someone to remain without intake for 12 hours, true?
A. I know that there is no nursing note that stated that -
MR. POWER: Objection. Move to strike.
THE WITNF??: - during the night.
THE COURT: Sustained. Answer will be stricken as nonresponsive. Jury will disregard the witness's answer. BY MR. POWER:
Q. If you as the physician wanted a fasting blood sugar level, it would be incumbent upon you to tell that patient do not eat for 8 to 12 hours, true?
A. The only way we write the fasting blood order is blood sugar in the morning, fasting blood sugar in the morning.
Q. Sir.
A. That's how the order is written. Just telling you how it's written.
Q. I'm not asking you how it's written. I'm asking you, sir, is it incumbent upon you as a physician if you want a true fasting blood sugar level to tell the person not to eat between 8 and 12 hours before you take it?
A. In the ambulatory setting, yes.
Q. Okay. Well, the eating prohibition doesn't change if you're laying in a nursing home and can get up and go snack, does it?
A. You don't tell your hospital patients not to eat when you??ier a fasting blood sugar. You just order the blood sugar.
Q. And then you just take into consideration whether they may have snacked the prior evening which may have altered the rate; is that true?
A. You rely on the nursing staff to be certain the patient does not have an overnight snack.
Q. Okay. So whether you tell them or whether you rely on the nurses, you expect no snacks or intake overnight -
A. Yes.
Q. - to get a true -
A. Yes.
Q. - fasting blood sugar? Accurate?
There's no order in the chart on - at any time at the Ingalls admission between January 19 and February 1 to keep this man without any snacks between - excuse me, not between - overnight, true?
A. True.
Q. Okay. There's no note in the chart of February 1 not to keep Mr. Carter NPO or without food overnight before taking that blood sugar, true?
A. True.
Q. Okay. Now, it's your opinion that if Mr. Carter di??t receive his baseline dc of 22 units daily or whatever base dose was needed, his insulin level would be elevated at all times, true?
A. False. You said insulin levels would be elevated.
Q. I'm sorry. Blood sugar levels would be elevated at all times, true?
A. True.
Q. Is it your opinion that Mr. Carter, his diabetes could not have been managed with Humulin R even if he was given an injection every single time his blood was tested, true?
A. True. Because he was not given the Humulin R until he went over 200.
Q. Sir, it's your opinion that Mr. Carter could not have been managed even if he was given insulin every single time they checked his levels, true?
A. I never said that.
Q. So you would agree that it would be appropriate under certain circumstances to manage an insulin dependent diabetic like Mr. Carter on Humulin R if it's given at the appropriate levels, true?
A. Exactly.
Q. Okay.
A. If??quently and treating nor?? blood sugar.
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Everything after “exactly” will be stricken as nonresponsive. The jury will disregard that portion of the witness's answer.
Answer just - confine your answer to the questions that are asked. If counsel for the plaintiff wishes to ask you anything, he has the opportunity to do so.
THE WITNESS: Yes, sir.
BY MR. POWER:
Q. Sir, isn't it true that if they - excuse me. If the nurses at Imperial provided Mr. Carter with short acting insulin at every reading, that they would have, in fact, been treating his diabetes?
MR. SHAPIRO: Object. Object to conduct of the nurses in treating.
THE COURT: Will you read the question, please.
MR. POWER: I'll withdraw and rephrase it. BY MR. POWER:
Q. You would agree with me that if he was tested four times a day, before meals and at bedtime, and if after every reading he was provided with short acting insulin, they uld have been treating Mr Carter's diabetes, correct?
A. Yes.
Q. And that would have been an appropriate way to manage his diabetes, true?
A. Yes.
Q. Now, sir, you have never held yourself out as an infectious disease specialist, true?
A. Correct.
Q. That is a separate area of medicine that deals solely with infections or causes and how to treat, true?
A. It's a separate subspecialty of internal medicine, but part of internal medicine is infectious disease.
Q. After you become an internist, you can go various ways, you chose endocrinology and there are people that go on to become infectious disease experts, true?
A. Choose the subspecialty. But you still treat the other subspecialties.
Q. Well, sir, in certain cases where you have had patients that are infected you've consulted infectious disease specialists, true?
A. Of course.
Q. And u rely on infectious dise specialists to contribute their area of. specialty to the care and treatment of a patient, true?
A. True.
Q. And when patients become infected, it's an appropriate judgment call to bring in an infectious disease consultant, true?
A. It depends on the clinical situation. If it's a straightforward infection, very unlikely. If it's anything that might be difficult to manage, wouldn't hesitate.
Q. Okay. And you know that Dr. Santos was actually the infectious disease treating physician on this case both at the January 19 admission to Ingalls and on the February 20 admission to Ingalls, true?
A. Yes.
Q. In fact, you said you read his deposition, right?
A. Yes.
Q. Now, sir, you're telling me that with respect to the levels of normal or abnormal, the fasting or random, those levels are set and can't be altered by anyone's opinion because those are the levels, true?
A. Right. The diagnostic levels.
Q. Wei isn't it true that - sta e that.
Isn't it true that it's your opinion that before a meal anything over 125 is actually abnormal?
A. Fasting anything above 110 is abnormal. Above 125 is diagnostic for diabetes fasting.
Q. You would agree with me, sir, that any - it is your opinion that any fasting blood sugar level before a meal over 125 is the first time it's called abnormal, true?
MR. SHAPIRO: Object to the question.
MR. POWER: He's -
MR. SHAPIRO: Object to the question.
THE COURT: Sustained. Sustained.
THE WITNESS: Medically you're wrong.
THE COURT: Objection is sustained. There's no question pending. BY MR. POWER:
Q. Sir, when you call a blood sugar level abnormal before a meal, it would have to be above 125 before you would call it abnormal, correct?
A. Counsel, you're equating fasting to before meals as being the same. They're not.
Q. Okay.
A. That's where we're having the difficulty communicating
Q. I don't want to have difficulty. And I apologize.
So you would agree with me, then, that there's a different upper end of normal if you don't order fasting but just ask for it to be done before meals?
A. Correct. And that's called an AC. And again, that's 140. Any - any blood sugar other than a fasting, 140 is abnormal.
Q. Wasn't it true it's your opinion that anything over 125 is abnormal?
A. Well, that's diagnostic. A fasting above 125 is diagnostic for diabetes.
MR. POWER: Objection, move to strike.
THE COURT: Overruled.
BY MR. POWER:
Q. Sir, I'm asking -
THE COURT: Counsel, if you know what diagnostic is and in fasting, you wouldn't be asking the question that you asked.
THE WITNESS: Thank-you. BY MR. POWER:
Q. Sir, it's your opinion that when you call a blood sugar a?rmal before meals, that 1 el is over 125, correct?
A. Abnormal and diagnostic -
MR. POWER: Objection. Move to strike.
THE COURT: Overruled. You may answer the question.
THE WITNESS: 125 would not be diagnostic for diabetes AC before a meal. But would be abnormal. BY MR. POWER:
Q. Fair enough. And anything above 140 after a meal you would consider abnormal, true?
A. True.
Q. Now, sir, if Mr. Carter was treated with Humulin R as ordered on February 1, if you accept that that initial order actually was ordered and placed on the chart and it was the intention of Dr. Azaran to have that in place through the entire admission, if it was actually ordered and carried out throughout that entire time frame, you would agree with me that it would - this patient would have been less likely to sustain the aspiration pneumonia, true?
MR. SHAPIRO: Objection. Form of the question.
THE COURT: Overruled.
THE WITNESS: Disagree. That order says DC. That was the order\at has his signature.
BY MR. POWER:
Q. Maybe you didn't hear my question. Let me rephrase it. If you assume that the order for blood glucose monitoring and sliding scale Humulin R was in fact an order that was placed on the chart and it was the intention to complete that BGM coverage throughout the entire admission, sir, if you accept that as true as a hypothetical.
A. The only thing I see is DC.
Q. Sir -
A. That's the only thing I see.
Q. You are aware there is a dispute between Dr. Azaran and the plaintiff as to whether that was ever DC, true?
A. Yes.
Q. So without getting into the truth of - first of all, you're not here to offer which version is true, correct?
A. Well, what was ordered? I don't know what was ordered because the only thing I see is DC.
Q. If you assume, sir, then, without looking at the chart, that Dr. Azaran wanted and in fact ordered -
A. And what was he ordering? What did he order?
Q. BGM iverage, sliding scale ins in Humulin R, Humulin R, BGM monitoring before meals and at bedtime with a sliding scale of insulin Humulin R at five units over 2, seven units over 3, which is, by. the way, exactly what you saw on the 2/1 order if you remove the letters DC, correct?
A. Okay.
Q. If you accept that version as true, you would agree that this patient would have been less likely to sustain aspiration pneumonia, true?
MR. SHAPIRO: Objection. Less likely than what?
THE COURT: Sustained. BY MR. POWER:
Q. It would have been less likely than if he remained completely uncovered, true?
A. Within reasonable certainty, true.
Q. You would agree that it would have been less likely he could have sustained a urinary tract infection, true?
MR. SHAPIRO: Object. Less likely than what?
THE COURT: Sustained. BY MR. POWER:
Q. Less likely than if he received no Humulin R or no coverage that he would have sustained a urinary tract infecti'?
MR. SHAPIRO: Objection.
THE COURT: Overruled.
MR. SHAPIRO: Judge, he said Humulin R.
THE COURT: That's what the question was. 1 MR. POWER: That was the hypothetical.
MR. SHAPIRO:. How can it -
MR. POWER: - bleeding, no Humulin R -
THE COURT: Hold it. Hold it.
MR. POWER: Judge, I'll rephrase.
THE COURT: Hold it.
MR. SHAPIRO: I'm sorry. I apologize.
THE COURT: You both have been admonished previously not to argue objections in front of the jury. Jury will disregard the comments and remarks by counsel for both the plaintiff and the defendant. They will be stricken. Take a brief recess.
(The jury left the courtroom.)
THE COURT: The next time either of you argues an objection in front of the jury it will cost you $500. I will hold you in contempt of court for violating my order.
Doctor, please answer just the question that is asked of you. If Mr. Shapiro wishes to go into any areas with yc m redirect examination, h has that opportunity to ask you questions and you can explain your answers.
THE WITNESS: Thank-you.
(A short break was taken.) (Whereupon, the following proceedings were held in open court.)
THE COURT: You may proceed.
MR. POWER: Thank-you, your Honor. BY MR. POWER:
Q. I'm going to give you a series of questions that are to be based on one hypothetical. Fair?
A. Correct.
Q. The hypothetical that I want you to accept is in comparing whether these problems would have developed is no glucose monitoring coverage with insulin, Humulin R, five units of 200, seven units of 300 versus getting the coverage of Humulin R at 200 and 300 on BGM readings at five units and seven units. Do you understand the two scenarios?
A. Yes. One no coverage and the other the coverage with five units for 200?
Q. Seven units for three.
A. Oka:
Q. You would agree with me that it would be less likely to sustain a urinary tract infection during the February admission of 1995 if he was on the Humulin under part two of my hypothetical?
A. Getting it.
Q. Yes.
A. Less likely, yes.
Q. In fact, you would agree it would have been less likely he would have sustained an MI, correct?
A. Yes.
Q. You would agree it would have been less likely he would have suffered atelectasis, correct?
A. Yes.
Q. You agree that all of these things would have been less likely because the sugar never would have gone up to 620, correct?
A. Yes.
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