Nursing Home Examination 3 - Direct and Cross of Internist - Part 4

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Q. Now, you would agree that without speculating the only problem you can say was more likely true than not still have occurred if he had received the glucose that we talked about under part two of that hypothetical.
A. Counsel you just lost me. Start - you said speculation.
Q. Same hypothetical with and without. You would agree that with, the only problem that you can say that's more likely true than not to still have occurred in this patient between February 1 and February 20 would have been the healed decubitus ulcers, true?
A. It's speculative you said. You said to go ahead and speculate?
Q. Without speculating, sir, the only problem that you can say was more likely true than not to have still developed in Mr. Carter between February 1 and February 20 if he received the glucose - excuse me, the Insulin, was the healed decubitus ulcer, true?
A. I'm a reasonable intelligent guy, you're losing me. I don't know the question.
Q. We talked about things that were less likely and you mentioned a bunch of things, true?
A. True.
Q. And, in fact, you wouldn't be able to tell me if those items, whether they were more than 50 percent likely to occur or less than 50 percent likely to occur if he had received the insulin, true?
A. True.
Q. Okay. However, it is still your opinion, though, that;n if he received the Humu n R he still would have gotten the decubitus ulcers on the heel, true?
A. Well, I respond to that the same way the other.
Q. Okay.
A. Is that he was more likely to have gotten it because he didn't get the Humulin R but still likely that he would have gotten it -
Q. Right.
A. - even if he did get it as he would have likely gotten the other things, though he was less likely to have had he gotten it.
Q. So it's your opinion today even if he was on Humulin R that it was still more likely true than not, more than 50 percent likely, that he would still suffer the UTI, the aspiration pneumonia, the MI, and the atelectasis, true?
A. He still likely would have gotten those morbid conditions?
Q. Yes.
A. Yes.
Q. Do you remember ever giving an answer under oath to the contrary?
A. I r imber giving an answer wit probabilities and it was highly speculative.
Q. Right. And without speculating, the only problem that you believe was still more likely true than not to have still developed in this man between February 1 and February 20 would be the healed decubitus ulcers, the rest of them, you would be speculating to try to determine whether they were more likely to happen or less likely - less than 50 percent likely to happen, true?
A. To put some logic into this whole line of questioning, the one thing I can say without speculation is that it was - it would have been less likely for him to have all the morbid conditions that he had, had he gotten the R. I can't give you any probabilities, decubiti included.
Q. Okay.
A. It would have less likely, 10 percent less likely, 90 percent less likely. Without speculation I cannot answer that.
Q. Fair enough. Now, when you were reviewing the Ingalls chart from January 19 to February 1, you were aware that his calorie or excuse me his oral intake was decreased based on the GI note of January 25, true?
A. Not- ised on the nursing notes. The nursing notes -
Q. I'm asking you, Doctor, did the GI note of January 25 note a decreased oral intake?
A. Can you read the GI note?
Q. I think you have it in front of you.
A. On the 25th? I'm going to have it in two seconds.
Q. You might get there quicker than I am.
A. I'm on the 25th. He says a downward.
Q. I apologize.
A. A decreased PO intake.
Q. Thank-you.
A. On the 25th.
Q. Fair enough.
A. Will not bring the calories PO.
Q. That was a note of, actually, Dr. Azaran,
correct? Page 88 of defendant's exhibit.
A. Right. Actually it says GI notes review.
Q. Correct.
A. So it's not the GI note.
Q. That's what I started to say. I apologize.
Dr. Azaran notes on January 25 that the GI notes were reviewed, correct?
A. Yes.
Q. And notes that there was due to a decreased oral intake, will not limit calories by mouth, true?
A. True.
Q. The GI note just below that says on the second line, eating poorly, true?
A. True.
Q. It says that the recommendation both - or of the GI on the 25th was a possible G tube if not improved, true?
A. In the same note from the 25th?
Q. Yes, sir, still on page 88. I think you will find the page numbers in the lower right-hand corner. They're Bates stamped.
A. Yes. Question mark, G tube if not improved.
Q. Fair enough. You would agree at that point that there was concern over eating, possibility of placing a G tube due to those eating concerns?
A. True.
Q. You would agree with the fact that if there is a problem eating, that can affect insulin levels, excuse me, the need for insulin based on blood sugar levels?
A. True.
Q. Now, I think you told us earlier that you believed the r. showed that he was eatin fine at the end of his admission to Ingalls, correct?
A. Yes. The nursing notes clearly indicate adequate intake, 2200 calories per day.
Q. For two days?
A. Right, at the end. As you said at the end of his stay at the Ingalls.
Q. And then by looking at the food intake at Imperial the first three days, you saw that on the calorie sheet he received or he took in less than a thousand a day or about a thousand a day during that calorie count during the first three days of the admission, true?
A. Well, I was confused there because the nursing notes say good appetite. So there was a disconnect that I couldn't understand for certain.
Q. Sir, you did see the calorie counts show that he took in about a thousand calories a day for the first two days that you can add up all three meals, true?
A. The calories that were counted, that were counted.
Q. Doctor, are you telling us today that you have reason to question the ability of a nutritionist to count calories?
MR. SHAPI : Object.
THE COURT: Sustained.
BY MR. POWER:
Q. Do you have any reason to doubt the calorie numbers on the calorie count filled out by the nutritionist on a calorie count chart that was completed during those three days?
MR. SHAPIRO: Objection, no foundation.
THE COURT: Sustained. BY MR. POWER:
Q. If you accept those as true, you would agree that that is a decreased oral intake for calories if he was only receiving approximately a thousand calories a day, true?
A. True.
Q. You noted that there was a request and an order to permit Mr. Carter to get food by syringe as early as February 2, true?
A. True.
Q. They ordered a pureed diet instead of just regular food, right?
A. True.
Q. A pureed diet is given to patients who have problems chewing food or eating regular food that comes with every pi: meal, right?
A. True.
Q. The pureed diet is given to try to help offset the problem chewing or eating, true?
A. True.
Q. And that was done on February 2, correct?
A. Correct.
Q. In addition, you will note that on the 12th Dr. Azaran entered a telephone order because of a swallow study to consider a G tube again because there was decreased oral intake, true?
A. On the progress note of the 12th?
Q. On the right side, the physician's order sheet. Let me see if I can get you a page.
A. Yeah. Give me the page. That would help. I have the physician orders from the 12th.
Q. You can help me. What page?
A. Yeah. Here, let me show you what I've got.
Q. What page number?
A. Page 151. And there's two orders from the 12th.
Q. Okay. Let me take you back to page 147.
A. I'm there.
Q. On the right-hand side of that sheet on the JCAHO's Health ‘are Systems physician ord sheet in the chart copy -
A. Okay.
Q. - February 12 it indicates discussed possibility of tube feeding with physician and family as calorie and protein needs are not met with oral intake per the three-day calorie count, true?
A. Yes, true.
Q. There were some adjustments made to try to help improve the nutritional status of the patient with health supplements and multi vitamins and ascorbic acids, true?
A. True.
Q. Those are typically given when the oral intake is not sufficient to provide protein, calorie and nutritional needs to a patient, true?
A. True.
Q. Now, I think you told us that you didn't see, and if I mischaracterize your testimony, please tell me, any problems eating at all up until the last two or three days at Imperial; is that your testimony?
A. I believe so.
Q. Okay.
A. I mean, did I give that testimony at the deposition?
Q. Earlier today.
A. No.
Q. Okay. You would agree with me that the appetite was described as good or fair and that bounced up and down throughout the admission?
A. Right. It was about the 16th, 17th that there was a - just looking at the nursing notes, that there was a change in the appetite.
Q. So you didn't see any evidence of only a fair appetite any time before the 16th?
A. Well, one thing I did note -
MR. POWER: Objection, move to strike.
THE WITNESS: - regarding the appetite -
THE COURT: Sustained. BY MR. POWER:
Q. Did you or didn't you see in the nursing notes a description of a fair appetite before February 16?
A. Recollection is only a good. It was on the 17th that a fair appetite was mentioned.
Q. And you specifically looked at those records in formulating your opinion that the appetite was good up until the end of the admission, right?
A. Okay. Yes, yes.
Q. Oka I don't want to rely on mory, so let's go back to the chart, and I'm going to direct you to starting on February 4 at the bottom of the page at 10 a.m., doesn't it include -
A. Give me the page number.
Q. I'm sorry. I apologize.
This is my copy and I did not number them. Let me go to another.
A. No, I have numbers on these.
Q. Just give me one moment, Doctor. Page 165.
A. I'm there.
Q. You would agree with me that at 10 a.m. at the bottom of that entry it shows that fluids were being pushed but only fairly taken, true?
A. I see good appetite.
Q. Okay. But you would agree with me at the bottom it says fluids pushed but fairly taken, true?
A. Yes, that's what it says.
Q. Decreased fluid intake can cause dehydration, true?
A. Yes.
Q. You would agree with me that on February 9, which would be page 168.
A. Can I amend my answer to the last answer?
MR. POWE Objection. Move to strj
BY MR. POWER:
Q. You gave me an answer.
MR. POWER: Objection, move to strike. Nonresponsive.
THE COURT: The witness wishes to correct an answer. He should be allowed to correct an answer. Go ahead, you may.
THE WITNESS: Thank-you, Judge. The - you may have poor fluid intake, but if you eat enough food, we get fluid from food, so your actual fluid intake could be diminished but you would not get dehydration assuming that you have adequate solid intake from which we get a good amount of fluid. I mean, it's just more precise answer. BY MR. POWER:
Q. So if you eat hamburgers and fries but don't drink anything for two days in a row, you don't get dehydrated?
A. Or if you drink half amount of what you normally would drink, no, you would not get dehydrated assuming you eat enough solid food from which we do get fluid.
Q. Direct your attention to page 168. Before I get there, yo-?? agree with me that?? ids are important for hydration?
A. Yes. Yes.
Q. And if you have problems with fluids, generally you can associate there's a likelihood that you're going to have a problem with hydration unless somehow you increase your oral intake for solids to pick up those fluids?
A. Total agreement.
Q. There's no increase of an appetite at all throughout this entire admission, true?
A. Well, numerous notations good appetite.
Q. My question is, there's no evidence of increased appetite at any time during this admission, true?
A. I cannot answer that because I don't know the precise definition of good by the person who was putting these notes into the record.
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Overruled.
BY MR. POWER:
Q. You have no opinion to a reasonable degree of certainty as to whether there was or wasn't at any time increased??
MR. SHAPIRO: Objection. Asked and answered.
THE COURT: Overruled.
THE WITNESS: I have no opinion as to whether or not there was an over. The question was, was there over intake?
BY MR. POWER:
Q. Increased appetite.
A. Increased appetite. I cannot offer an opinion.
Q. Okay. Going to page 168, then, at the bottom starting at February 9, the third line of that entry.
A. There are three entries from February 9. Which one?
Q. I'm sorry. 10 p.m.
A. 10 p.m. Okay.
Q. Third line down, right corner of the page, fair appetite, true?
A. My - my copy's a little weak. Let me look at yours. It looks like fair appetite, but do you have a better - better copy?
Q. I believe I do.
A. How come us witnesses get the bad copies and you lawyers get the good ones?
Q. Copy service. I'm going to?? your attention to this -
A. I see. Yeah, fair appetite.
Q. Okay. So you would agree with me that there were appetite problems noted in the chart on - or appetite descriptions other than “good” earlier than the 16th?
A. Yes.
Q. You just didn't see those when you reviewed the chart?
A. Well, I saw many more good appetites than I did fair appetites.
Q. You would agree with me that there were fair appetites -
A. Yes.
Q. - noted in the chart -
A. Yes.
Q. - before 16th and 17th, true?
A. Yes.
Q. Thank-you.
And you would agree with me that a swallow study would be important to do if there was concern about appetite? Well, strike that. Let me withdraw the question.
A swallow study would be one of he appropriate diagnostic tools to use when you're concerned about appetite, true?
A. Well, first study I would do would be a blood sugar. Rule out a horse before I start looking for zebras.
Q. Would you agree with me that a swallow study is one of the diagnostic tools that can be used when there is a decreased appetite?
A. Not an initial study for decreased appetite.
MR. POWER: Objection. Move to strike as nonresponsive.
THE WITNESS: Again, you look for horses before you look for zebras.
THE COURT: Answer will be stricken as nonresponsive. The jury will disregard the answer.
BY MR. POWER:
Q. You will agree with me that a swallow study is one of the appropriate tools that can be used to assess a patient when there is a decreased appetite, true?
A. If you can state in your question a time line, I'11 tell you when -
MR. POWER: Objection, move to strike as nonresponse.
THE COURT Sustained. The witness answer will be stricken. The jury will disregard the witness's answer.
BY MR. POWER:
Q. Can you tell me, Doctor, whether you agree that a swallow study is an appropriate tool that can be used when there is a concern about the ability to eat and decreased appetite?
A. I disagree.
Q. Fine. Sir, I'm going to switch gears for a minute, and you show or Mr. - excuse me. Mr. Shapiro showed you some medical bills from the hospital stay at Ingalls.
A. Yes.
Q. Remember seeing those? They were right there. And you had previously told us that every expense was related and then took off a couple of those expenses, right?
A. Yes, expense for Dilantin and ferrous sulfate.
Q. And you took those off because they would have been given anyway if he had stayed at Imperial because those were things he was on before the elevated sugar issue came up, true?
A. Yes.
Q. So?? you looked back through he chart, then, you took off those items which were, in fact, duplicative or would have been given - would have been given anyway, true?
A. Well, someone else took them off for me. I did not do the calculations.
Q. I'm not suggesting you're a mathematician. But you agree that those items'should not be on that list for purposes of the claimed damage in this case because he would have gotten those meds and he would have incurred those expenses anyway, true?
A. True.
Q. And then when you looked through that record, you knew that you needed to look through that record to determine which were related and which he would have received anyway, right?
A. True.
Q. So that when you came in here, you would have given us a fair assessment of only those damages that are related as opposed to things that he would have incurred anyway, right?
A. Well, what I would have done that was not done, which I disagree with -
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Sustained. Jury will disregard that and it is stricken. BY MR. POWER:
Q. It is your opinion that everything other than those items that are removed from that bill are due to this direct conduct upon my client and the problems associated with the hyperglycemia, correct?
A. Correct.
Q. It is your opinion that none of those expenses would have been incurred by Mr. Carter if the hyperglycemia did not occur, true?
A. True.
Q. Sir, I think it's your opinion that he should have been monitored and given Humulin N, right? Mr. Carter, he should have gotten Humulin N as early as February 1, right?
A. Yes, yes.
Q. And he should have been on Humulin N the entire time, according to your opinion, right?
A. Yes.
Q. Okay. You didn't subtract the Humulin N that he got during that admission from that bill, did you?
A. No.
Q. Okay So now you agree that no - that charge isn't something that's related to the hyperglycemia but he should have been on it and would have been incurring those charges every single day because he should have been on Humulin N, true?
A. True.
Q. So that bill overstates the actual damages in your own opinion by all of the charges for the Humulin N, true?
A. True.
Q. Okay. Likewise, it would have been reasonable to put the patient on Humulin N with Humulin R coverage, true?
A. True.
Q. Humulin R is on that bill, isn't it?
A. Yes.
Q. So you overstate the bill again, didn't you? Because that is something that he should have gotten anyway, true?
A. True.
Q. Now, blood glucose monitoring, that's something he was supposed to have gotten, right?
A. True.
Q. Once again you overstated that because he should have gc??en that done four times a day or once a day, whatever, at the hospital or excuse me, at Imperial, true?
A. True.
Q. Okay. There's charges for decubiti care in there, isn't there?
A. Yes.
Q. He had decubiti on February 1, didn't he?
A. Yes.
Q. He should have gotten decubiti care on February 1, right?
A. Had they not healed.
Q. Okay. And he continued to get decubiti care even after he had this episode of hyperglycemia all the way up until the time he died because he had those problems, true?
MR. SHAPIRO: Objection.
THE COURT: Sustained. BY MR. POWER:
Q. You reviewed this record to see whether the decubiti were exacerbated by this accident or whether they were caused by this incident or whether he would have had these problems in the natural course of his disease process, true?
A. Or they failed to heal because not being - administering insulin. So the decubiti care was a direct result of his failure not to get insulin because they never had a chance to heal.
Q. Is it your opinion that this 10 by 10, four centimeter deep single decubiti ulcer on his sacrum would have healed by February 20?
A. We'll never know because his blood sugar was 620.
Q. So you have no opinion one way or the other, true?
A. I have a strong opinion that it was never given a chance to have any chance of healing.
Q. Sir, you don't know whether it would have healed one way or the other without this hyperglycemic event, true?
A. It would not have healed because of the hyperglycemia and that I'm certain, absolutely'certain.
Q. After he.received the insulin post part 17th, the decubiti on his coccyx never healed, true?
MR. SHAPIRO: Objection.
THE COURT: Sustained. BY MR. POWER:
Q. In fact, after he was well controlled, his decubiti cont.- ‘led to progress as they ha before this incident, true?
MR. SHAPIRO: Objection.
THE COURT: Sustained.
BY MR. POWER:
Q. You agree that his decubitus started January 2 or I'm sorry, late December after he became a paraplegic, true?
A. Rephrase the question.
Q. Sure. Before he became paraplegic he had no decubitus ulcers, true?
A. True.
Q. Before he became paraplegic his skin integrity was intact, true?
A. True.
Q. After he became paraplegic, a small sore started on his coccyx, true?
A. True.
Q. And by - from December 17 to January 2 when he was debrided -
A. Give me the dates now.
Q. Sure. December 17.
A. ‘94.
Q. Correct. To January 2, ‘95 the decubitus ulcer grew to- he point where it was 8 by”. centimeters and had to be debrided or operated on to carve out all the bad, dead tissue by Dr. O'Donnell at Glenwood Terrace - excuse me, at St. James because despite Humulin N and Humulin R, this man's decubitus progressed from nothing to 8 by 6 centimeters with a one or two centimeter depth defect, true?
A. True.
Q. So you would agree with me that even under control with the N and the R this man deteriorated from his decubiti because that is a problem associated with being diabetic and bedridden, true?
A. Well, despite being given the N and the R, his control was less than optimal. And that is one of the contributing factors to the decubitus developing as well as getting worse.
MR. POWER: Objection. Move to strike as irrelevant to the conduct of my client and the care of my client for this patient's condition.
THE COURT: Overruled. BY MR. POWER:
Q. So it's your testimony that his decubitus was getting worse anyway'because his diabetes weren't controlled as early as December?
A. Wei] not optimally control.
Q. So before my client ever saw this patient, he was already on the downhill spiral because his diabetes wasn't controlled, right?
A. Well, I'd have to have the exact measurements from his admission to the Imperial and from the measurements from the earlier days.
Q. The reality is you never looked at that stay in detail to determine how controlled or out of control it was?
A. The reality is I don't remember the dimensions of the decubitus. That's the reality.
Q. I'm going to show you two pages from Defendant's Group Exhibit 11 which is the St. James admission from December 10 through January 13. I'm going to show you two separate documents from that admission. One was a consultation by Dr. Sardar, S-a-r-d-a-r which was completed on January 2 and the actual operative report from Dr. Sardar which was completed on January 2. If you'll take a minute and just look at these two pages.
A. There's no dimensions.
Q. Well, first of all -
A. Can't compare them without dimensions.
Q. Fir. of all, I did do - well, 1 et me do it this way. You agree this consultation record indicates when he came in he didn't have any decubiti, and when he operated on January 2, he operated on decubitus ulcer of the sacrum, true?
A. Well, I know from the date of the operation which is 1/2.
Q. Yes, sir.
A. The debridement.
Q. Okay.
A. I don't see any dimensions.
Q. If you will give me a second, I'll get you the page.
A. There's a dimension of a specimen on one of the pages you did not give me.
Q. That would be the path report, correct?
A. That was a path report. But that's the specimen. It's not the measurement of the gaping hole.
Q. Specimen would be smaller than the actual hole, correct?
A. That's an assumption. I couldn't say one way or the other.
Q. Well, you can't take something out and have the stuff that you took out be larger than the hole, right?
A. In the Formalin or whatever they may use to preserve it in, could be soaked up by the tissue and actually increase the dimensions of the tissue.
Q. Let me do it this way. You reviewed the records, true?
A. True.
Q. If the records show, and the records are in evidence, so if the records show a 10 by 10 centimeter decubitus with some depth to it, you have no reason to dispute those measurements, true?
A. True.
Q. Fair enough.
A. And the date of that measurement was again around January 2?
Q. Correct. Before he was ever admitted to Imperial for the first time. Now, sir, you looked at the dimensions when he was admitted to Imperial on January 13, right?
A. Yes.
Q. And, in fact, at that time it was a 10 by 10 centimeter, right?
A. Again, you'll have to before I answer -
Q. Sure.
A. I' d. “ike to see.
Q. I don't want you to guess. Let me just show you the.....
A. I have my copy right in front of me. Just yell a page number. Save some time.
Q. I believe your - just give me one minute.
A. Ten by ten dated - well, 10:30 a.m. 1/13/95, 10 by 10 centimeter in size. So it was no different.
Q. Sir, I'm going to show you the skin assessment I will mark as Defendant's Exhibit No. 12 from the January 13 admission to Ingalls.
(Defendant's trial Exhibit No. 12 was marked for identification.)
THE WITNESS: The dimensions on page 20 of what I just quoted from the nursing note from 1/13 is 10 by 10. BY MR. POWER:
Q. Showing you what's been marked as Defendant's Exhibit 12, this is the nursing admitting note and assessment for Paul Carter on January 13, 1995, true? A. I don't have my bifocals on. I'm not vain. Yeah, that's dated and had the same - an hour difference in ‘ime.
Q. Just if you will give me a minute. There is a description of a stage four]decubitus ulcer of 10 by 10 centimeters in size with 4 centimeters in depth on that chart, correct?
A. Well, same as this note which is 10 by 10 but does not give the depth.
Q. You would agree that the chart also shows there was dryness of the heels noted on January 13, 1995 to Mr. Carter when he first came to Imperial Nursing home based on the chart, Defendant's Exhibit 12, true?
A. Yes.
Q. Okay. And dryness of the heels is one of the first signs that you would see when the skin is not receiving enough oxygen to the heel, the earliest stages of the development of decubitus ulcers, true?
A. I can't make that statement. I'm not refuting your statement. I would not make that statement, a dryness is a first, finding of decubitus.
Q. Let me rephrase it.
A. Yeah, please.
Q. Dry skin on the heels is a nonspecific finding, but it could be associated with the early “signs of ulcers in the heels, true?
A. Yes Now, Counselor, on that there's a discrepancy.
THE COURT: There's no question.
MR. POWER: Thank-you, your Honor.
BY MR. POWER:
Q. Now, we were talking about the medical expenses when I side-tracked you on decubitus care. I apologize for that. But back to the medical expenses, you - he was receiving a Foley back as early as February 1, true?
A. True.
Q. He was going to be catheterized for the rest of his life, true?
A. Probably, most probably.
Q. He was incontinent of bowel and bladder, wasn't he?
A. Of bladder.
Q. And he was also incontinent of bowel, wasn't he?
A. I cannot answer that with certainty.
Q. Wasn't he being treated by the nurses at Imperial for incontinence of bowel before February 1?
A. He was receiving nursing care and that very often included hygiene in the anal area.
Q. Now you would agree with me that charges associated with the Foley didn't change because he was in - excuse me, charges with the Foley that he would have received anyway were duplicative in the hospital, true?
A. Well, there was increased care regarding maintenance of the Foley because urosepsis, because of urinary tract infection.
Q. And you didn't subtract off those charges from the Foley he would have incurred anyway because he had a Foley and he needed a Foley?
A. True.
Q. Now, you knew on January 25 and January 26 based on the Ingalls chart that it was the suggestion of both Dr. Azaran and the gastroenterologist that Mr. Carter have a G tube inserted, true?
A. Yes.
Q. Mrs. Carter didn't want it at that time, right?
A. Well, he ate very well for Mrs. Carter.
Q. Mrs. Carter refused a G tube at that time, true?
A. True.
Q. You would agree with me that on February 23 the first this - one of the first thin they did for him - excuse me. You would agree with me that within a few days of admission to the hospital on February 20 they put a G tube in, right?
A. Yes.
Q. They simply performed that which Dr. Azaran and the gastroenterologist had suggested before February 1, true?
A. But the need on February 23 was much greater than the need prior to his admission to -
MR. POWER: Objection. Move to strike as nonresponsive.
THE COURT: Overruled.
BY MR. POWER:
Q. Without talking about his need or your assessment of the calories, you would agree with me that the G tube that was put in on admission to Ingalls on February 20 was the same G tube, same type of G tube that they had suggested on January 25 and January 26?
A. G tube was the same.
Q. Okay.
A. The indication wasn't.
Q. And the G tube has to be done in a hospital setting, true
A. No.
Q. Okay. Do you insert G tubes?
A. No. Proud of it.
Q. Now, Mr. Carter was wearing diapers when he became incontinent of bowel, true?
A. He was wearing diapers, yes.
Q. He was charged for diapers during the Ingalls admission, true?
A. True.
Q. Didn't subtract those off, did you?
A. No, did not subtract the diapers.
Q. The tube feedings that he was getting were the tube feedings associated with the G tube, right?
A. Yes.
Q. Is the same feeding that he would have gotten if the G tube had been placed February 25 - or excuse me, January 25 or January 26, true?
A. But the indication for the G tube did not -
MR. POWER: Objection. Move to strike, your Honor.
THE COURT: Sustained. The jury will disregard the answer. It will be stricken. BY MR. POWER:
Q. If he had undergone the G tube as suggested by Dr. Azaran on january 25, January 26, the ube feedings that he incurred during that Ingalls admission would have already been incurred, correct?
A. The assumption being again?
Q. That she consented to the G tube that Dr. Azaran suggested on the 25th or 26th?
A. But she didn't consent because he ate well for her. I'm confused.
Q. Doctor, if she consented to the G tube insertion on the 25th or 26th as Dr. Azaran suggested and as the gastroenterologist suggested, he would have began receiving G tube feedings, true?
A. If she consented?
Q. Yes.
A. Yes.
Q. So if she had followed Dr. Azaran's advice at that point, all of the tube feedings from the February admission to Ingalls would have been already being done because the tube feeding would have been started January 25, 26 or 27?
A. Yes.
Q. Okay. And you know on February 12 he noted that they were going to again talk to the family about a G tube being put in because the needs were not being met by oral intake according to the nutritio?ts, true?
A. Yes.
Q. So if in fact, the nutritionist went back to her again and said this man needs to be fed by G tube, had she consented, the G tube insertion, those charges are completely unrelated to the hyperglycemia, true?
A. Are you asking me a question of a man who was taking 2200 calories?
Q. Was he taking 2200 calories at anytime at Imperial based on any calorie counts?
A. Well, on Ingalls -
Q. At Imperial.
A. Of course not.
Q. Fine. If she had undergone the G tube agreement of February 12 when the nutritionist told her that the oral needs were not being met even after the pureed diet and supplements based on the calorie counts at Imperial, you would agree with me that the charges related to the G tube would have been due to the decreased oral intake starting on February 1 based on the calorie counts and not due to hyperglycemia, true?
MR. SHAPIRO: Objection. Assumes improper facts.
THE COURT: Sustained. Jury will disregard the question. It will be stricken.
BY MR. POWER:
Q. You would agree with me that if his food needs were not being met by orally, regardless of how we describe it, if there was an assessment made by a physician during the February admission?
A. Now, we're speaking - now - an assessment made by a physician.
Q. On February 1, February 2, February 3 based on the calorie counts of showing a thousand, approximately, calories a day, that this man could not meet his oral needs - excuse me, his calorie needs by oral intake, you would agree with me that the G tube, if it had been placed at that time, would be completely unrelated to the hyperglycemia, true?
A. The assessment would have included a blood sugar and then they would have had the answer to why he was not eating.
Q. Sir, is it your testimony that he never would have needed a G tube if he didn't have this one 20-day episode of hyperglycemia?
A. Yes. That is my opinion with reasonable certainty.
Q. Now, sir, he was receiving mattress pads for decubiti care at Imperial, true?
A. Yes
Q. He received mattress pads for decubiti care at Ingalls, right?
A. Yes.
Q. He was given peri washes as natural washes that go along with the sacral area of clean up at Imperial and at Ingalls, true?
A. True.
Q. Didn't subtract any of those, correct?
A. True.
Q. He was paying for a bed at Imperial to actually stay there and eat, right?
A. True.
Q. You didn't subtract off that cost from the bed charges or the eating charges at Ingalls, true?
A. I would not have subtracted those costs had he been at home.
Q. Sir, he wasn't going home on February 1, he wasn't.
A. I understand. But you have to sleep somewhere. Do you put the man out on the street?
Q. Sir, on February 20 to March 17 if he had stayed at Imperial, he would have paid for a bed and paid for meals every single day, true?
A. At much lower rate.
Q. And you never did anything to try to subtract off that amount so that only the incremental difference would have been included in this bill that you claim are related -
A. True.
Q. So you would agree that based on all the things we just discussed, you overstated when you told this jury that all of those charges are related for each and every one of those items that you and I just went through, true?
A. True.
Q. Okay. Now, sir, you are the chairman of two different companies - strike that.
You're the chairman of a company that sells insulin sensitizing products, true?
A. (No response.)
Q. Is - Akesis sells a sensitizer for insulin?
A. Yes.
Q. For diabetes. I apologize. It is an insulin sensitizer for diabetes, true?
A. True.
Q. And you're the chairman of the board for that company, right?
A. Yes
Q. Is it your job to sell and promote the company's interest in selling that product, true?
A. Yes.
Q. You are the chairman running appropriation that develop software programs for cancer, right?
A. For cancer?
Q. That's what is typed. I'm not sure if it's accurate.
A. You wouldn't want me near cancer.
Q. What software company -
A. I'm strictly a diabetes man.
Q. What software company are you the chairman of?
A. Myjeannie dot com.
Q. That has nothing to do with cancer, right?
A. No, nothing to do with cancer.
Q. If it says that in your transcript, it was a typographical error, right?
A. I don't know where you got that from.
Q. In any event, that company, as the chairman, it's your job to run it and develop products within it and promote the products for sale?
A. I'm the chairman of the board. I don't have an active role in the day-to-day operations.
Q. As rairman of the board you're supposed to oversee the financial health of the company, true?
A. Well, actually the CEO, Larry Cane does that.
Q. So you have no role in the successful management or operation of the company as the chairman of the board?
A. No. Chair the board meetings.
Q. You told us that you had a medical license, I believe, in Pennsylvania?
A. Yes.
Q. The only reason you got that was so that you could become a medical director of a corporation that sells glucose sensors, right?
A. Well, no, we did research. I was doing research in Pittsburg.
Q. You couldn't - strike that.
You never practiced in Pennsylvania, right?
A. Well, I did research. Yes, I did practice.
Q. Did you ever practice in primary care in Pennsylvania?
A. No.
Q. Did you ever have patient care in Pennsylvania?
A. Yes, as part of the research study.
Q. Did -you ever treat nursing home Patients in Pennsylvania?
A. No. And none of the patients became nursing home patients.
Q. Now, sir, you knew before this incident that Mr. Carter had preexisting problems associated with his diabetes and his paraplegia, right?
A. Yes.
Q. He was also post stroke, right?
A. Yes.
Q. And post stroke individuals have risks of aspiration?
A. Yes.
Q. Diabetics are at risk for peripheral vascular problems, true?
A. Yes.
Q. When we talk about peripheral vascular problems, we're talking about - strike that.
I want to make sure you and I are talking about the same thing. Talking about the compromised blood flow in the small vessels down in the tissues in the buttock or the heel - excuse me, not buttock, in the heel which could stop that tissue from being healthy, right?
A. Yes
Q. Those peripheral vascular problems put him at risk for the development of decubitus ulcers on his heels, right?
A. Yes.
Q. Man was bedridden, right?
A. Yes.
Q. So when we take a diabetic that, has peripheral vascular problems and make them bedridden, that is just a complicating factor on top of the diabetes making him at higher risk for the development of bed sores, true?
A. Absolutely.
Q. And, in fact, this man's skin integrity was very fragile because he developed bed sores within - significant enough to be debrided within 15 days of first being bedridden, true?
A. Yes.
Q. Now, the sacral decubitus ulcer - do you need to take a break?
A. I want to put some medicine on my lip.
MR. POWER: I'm sorry, Judge. I saw him.....
THE COURT: How much longer do you anticipate being?
MR. POWER: A lot.
THE COURT Ladies and gentlemen, it's probably a good time to break for lunch. Because I anticipate breaking early today, you won't be here past 3 o'clock, we'll take an abbreviated lunch from what you had from the last couple of days. But please be back here by 1:30. That's an hour instead of an hour and a half. And we won't go past 3 o'clock today.
(Whereupon, further proceedings in said cause were adjourned to September 1, 2000 at the hour of 1:30 p.m.)
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