Nursing Home Examination 4 - Direct and Cross of Expert Witness Doctor - Part 2

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BY MR. POWER:
Q. I would direct your attention to Page 194.
A. Page 194. For day one, Mr. Carter consumed close to 800 calories the first day, close to a thousand calories the second day, on the third day he has an incomplete record but for two meals, about 800 calories for two meals out of the three.
Q. Now, Doctor, based upon the oral things that are referenced in the calorie counts, do you have an opinion as to a reasonable degree of medical certainty whether the treatment with Humulin R -and blood glucose monitoring and four meals a day before bedtime was appropriate for that admission?
MR. SHAPIRO: Objection, Rule 213.
THE COURT: Sidebar please.
(Whereupon, the following proceedings were had in chambers outside the presence and hearing of the jury:)
THE COURT: Will you read the question please?
(Whereupon, the record was read as requested.)
MR. SHAPIRO: Your Honor, my objection is that he never explored the basis of his opinion on the calorie counts.
MR. POWER: Judge, he said he looked at the entire chart and his clinical situation - it's based on his entire clinical condition at that nursing home based on these very records that Mr. Carter's blood glucose monitoring four times a day and Humulin R was appropriate.
It was disclosed. He went into it in his dep, he just went into it on direct. I mean it's already in evidence that this is the clinical factual scenario he was faced with during this admission when he said Humulin R was appropriate.
MR. SHAPIRO: Judge, the problem is he's already been asked the question whether management, the way Dr. Azaran gave him Humulin R and blood glucose four times a day was appropriate, he said it was.
Now, he's asking another question and now he's asking whether that management was appropriate on the basis of the calorie counts. That was never disclosed. This is a whole new theory that the defense has come up with at the time of trial that there was some change in the management based on these calorie counts.
At the time of his deposition, and I'll show this on cross-examination, Dr. Danko's opinion from reading Dr. Azaran's deposition was that he intended the patient to be on Humulin N, plus the Humulin R.
So this whole concept of calorie counts was never disclosed, he certainly never disclosed that as being the basis of his opinion.
Now, this objection of defense counsel is that now that there's reduced calorie counts, it's a whole different ballgame and that's just something that was never disclosed, never discussed at his deposition under Rule 213.
THE COURT: Is there an opinion with regard to the calorie counts in addition to the Humulin R and the blood glucose monitoring?
MR. POWER: Did he specifically refer to calorie counts?
THE COURT: You're asking for a specific opinion.
MR. POWER: Actually, Judge, it's almost in light of this, he said yes, not that is this a new basis. This is one of the critical factual items that he looked at. He said he looked at the entire chart.
He said there was no clinical change in this man's condition, that I will get into toward the end of my direct-exam, and that Humulin R in the like of this clinical scenario day by day was appropriate for this patient.
I guess what Mr. Shapiro is now saying is that I can't ask him anything about basically the clinical condition because Mr. Shapiro didn't talk to him about what the clinical condition was that he faced on a day-to-day basis.
I agree that I have to disclose opinions. My opinion was based on the clinical condition of this patient during this admission.
THE COURT: Read the question back please.
(Whereupon, the record was read as requested.)
THE COURT: And has he given an opinion with that as a basis?
MR. POWER: Specifically -
MR. SHAPIRO: Sorry, Counsel, no.
THE COURT: The objection is sustained.
(Whereupon, proceedings were held in open court.)
THE COURT: The objection is sustained.
BY MR. POWER:
Q. Doctor, would you agree with me that there would be no circumstance that you believe would be appropriate where you can discontinue insulin and monitoring on Mr. Carter?
A. I would agree, yes.
Q. And if Dr. Azaran did so, you believe he deviated from the standard of care, is that fair?
A. Yes.
Q. Is there any evidence based on your review of Dr. Azaran's testimony that he believes that he discontinued monitoring?
MR. SHAPIRO: Objection. He's asking to comment on the witness' testimony.
THE COURT: Would you read the question back please?
(Whereupon, the record was read as requested.)
THE COURT: Sustained as to the form of the question.
BY MR. POWER:
Q. Doctor, based on your review of Dr. Azaran's testimony, what did he testify to as to whether he continued or discontinued the blood glucose monitoring plus the Humulin R sliding scale?
A. In Dr. Azaran's deposition, he repeatedly stated that he wanted to continue the insulin treatment and monitoring that was ongoing at Ingalls Hospital.
Q. Doctor, I'd like to talk about the clinical condition of the patient regardless of whether the insulin was given or not given.
Did you find any evidence of clinical deterioration between February 1 and February 20?
A. I believe that the feeding became more difficult. I think the nurses were having a harder time with him as far as being less communicative. He was essentially vegetating in bed. There was several references that he was alert but not responding.
Q. Doctor, you're aware that Dr. Azaran saw the patient on the 16th for decubitus ulcers?
A. Correct.
Q. Doctor, do you have an opinion as to a reasonable degree of certainty as to whether Dr. Azaran needed to review the entire chart for that visit?
A. He was called in to see a specific problem. He had just seen the patient two weeks earlier.
So no, I don't believe a full examination and a full review of the chart was warranted at that point.
Q. And, Doctor, if he failed to review the entire chart, did he comply with the standard of care when he dealt with the decubitus ulcers?
A. No, he did not fail to comply.
Q. I'm sorry. My question was, did he comply with the standard of care if he did not review the entire chart on the 16th when he dealt with decubitus ulcers? Bad question.
On the 16th, based on his limited review to focus on the ulcers, did he comply with the standard of care?
A. Yes, I believe he did.
Q. Now, Doctor, do you have an opinion as to a reasonable degree of medical certainty as to why this patient was transferred on February 20, 1995, from Imperial to Ingalls?
A. The nurses became alarmed when his blood glucose monitoring showed to be excessively high. This followed a half a day or a day of his taking in even less foods than previously, so the nurses were alerted to a change in his condition.
Q. And when the BGM came back HHH, was the patient then transferred?
A. Yes, he was.
Q. Doctor, do you have an opinion to a reasonable degree of medical certainty as to why the blood glucose reading was HHH in Mr. Carter on February 20th, 1995?
A. He had developed an infection again and very typically when a diabetic develops an infection, the blood glucose rises precipitously.
Q. Doctor, in your opinion to a reasonable degree of medical certainty, was the patient's admission to the hospital due to the infection?
A. Yes, it was.
Q. And can you tell me the basis for that?
A. With the diabetes that badly out of control due to infection, you have to treat the infection aggressively.
Q. Doctor, he had a urinary tract infection on admission?
A. Yes.
Q. And was that urinary tract infection treated by Dr. Santos?
A. I believe it was, yes.
Q. Do you have an opinion to a reasonable degree of medical certainty as to whether the urinary tract infection was either caused by or exacerbated by the hyperglycemia that was seen on February 20th, 1995?
A. I don't think it was caused by or exacerbated by the hyperglycemia. I think the converse would be true, that the hyperglycemia was caused by the urinary infection.
Q. Can you tell me the basis for that opinion?
A. It's really a daily occurrence in diabetics whether they develop a urinary sepsis, a pneumonia or just a cold.
Typically, a patient will call and tell me that they're not eating, they've got a cold, a sore throat, they've lost their appetite, what should they do with their insulin.
And I advise them to stay with it because, if anything, they're going to need more that day. The stress on the body of an infection actually causes more sugar to be released from stored supplies.
We've got some sugar stored in our muscles, some stored in our liver. You can create sugar for fasting. And under the stress of an infection, our blood sugars will rise.
And so my advice to my patients is to take their insulin. I don't raise it because I don't know how far to raise it at that point. So I tell them to stay the course.
Q. Doctor, this patient had the hyperosmolar hyperglycemic state on admission to Ingalls?
A. I believe he did, yes.
Q. Do you have an opinion to a reasonable degree of medical certainty as to the cause of the HHS?
A. He was hyperosmolar because his sugar had risen. He was also hyperosmolar because he a mild dehydration and his blood urea nitrogen had risen. You know, those will raise the blood to osmolarity level.
Q. On admission to Ingalls, do you know how long the HHS was present?
A. I calculated that through the 25th. It began to diminish on the 25th.
Q. Doctor, on admission to Ingalls, did you note lower lobe abnormality found by the physicians?
A. There was a left lower lobe abnormality described that Dr. Santos attributed to atelectasis which is a compression of the lung tissue so that it's more prominent on X-ray.
And I believe there's also an abnormality of a pneumothorax on that side. There was some air leak between the lung and the chest wall on that side. The pneumothorax can cause an atelectasis.
Q. Clinically, did you see any change in his condition due to the pneumonia?
A. There was no evidence on admission that I could see from the chart that Mr. Carter had pneumonia, he was not short of breath, he was not described as being short of breath, he wasn't coughing profusely.
So there didn't seem to be evidence as reported in the chart of a pneumonia at that time.
Q. Doctor, with respect to the urinary tract infection, that was found on admission?
A. Yes, it was. The urine cultures grew out significant numbers of a urinary pathogen and Dr. Santos instituted measures to treat it.
Q. Doctor, do you have an opinion to a reasonable degree of medical certainty as to whether the infection that was found at Ingalls on February 20th was a new infection, an acute infection or a chronic one?
A. I believe it was a new infection. He had previously been treated for a urinary infection and I believe a different organism was grown at that time.
I don't recall offhand which one, but it was not the Providencia that was grown out on the 20th of February.
Q. What effect, if any, did the finding of neutrophils have on your opinion that it was acute versus chronic?
A. He had an elevated white blood count. The neutrophil count was high upon admission and subsequently came down so it looked like a new onset of infection.
Q. I'm sorry, a new onset -
A. A new onset of infection.
Q. What would you normally expect to see with neutrophils if it was a chronic infection?
A. Well, it wouldn't really be elevated to begin with. Chronic infections tend to be rather indolent and so you would see a baseline white count whether above normal or not and then it wouldn't necessarily change if the treatment wasn't effective.
Q. Doctor, you know there is some reference to a nontransmural MI and myocardial infarction- in the Ingalls records?
A. Yes, I saw that.
Q. Do you have opinion within a reasonable degree of medical certainty as to whether one actually occurred?
A. I'd be hard pressed to conclude that a MI occurred.
Q. Can you tell us why?
A. Well -
MR. SHAPIRO: Objection, Rule 213.
THE COURT: Sidebar.
In fact, ladies and gentlemen, take a recess for a few minutes.
(Whereupon, a short recess was taken.)
(Whereupon, the following proceedings were had in chambers outside the presence and hearing of the jury:)
MR. SHAPIRO: Judge, in his deposition when asked if the patient had a myocardial infarction, Dr. Danko said I would be very hard pressed to say yes or no on this matter.
Now, he says that - now he says in court that he would be hard pressed to say that he had a myocardial infarction, which to me is attempting to say that he didn't have one.
MR. POWER: If you read his entire answer instead of just the first sentence, you can see where he says I know there's an elevated myocardial band determined at the hospital, but there was no clinical evidence recorded. Nobody recorded a low blood pressure or unusual heartbeat, the EKG didn't change. So basing strictly on the MB band of a slightly elevated CPK is very hard to do to diagnose an MI.
That's exactly what he'll testify to today.
THE COURT: The objection is overruled.
(Whereupon, proceedings were had in open court.)
THE COURT: You may be seated. The objection is overruled.
MR. POWER: Your Honor, may I have the last question read back so that the witness could testify as to -
THE COURT: Could you read the last question and answer, if there was one.
(Whereupon, the record was read as requested.)
THE COURT: You may answer the question.
THE WITNESS: The only evidence that there was any cardiac event on the chart was an elevation of Mr. Carter's CPK. That's a blood test, creatinine phosphokinase.
And that's enzymes released from muscle when it's damaged. Heart muscle releases a slightly different band that we call myocardial band or the MB band.
When that's measured, it gives us an indication of whether there's been any significant heart damage or not.
At best it's been an unreliable test. In Mr. Carter's case, the elevation was not really significant.
BY MR. POWER:
Q. Doctor, was there any evidence of low blood pressure or an unusual heartbeat?
A. There was nothing recorded to make me think that there was any heart malfunction at all with either an abnormal heartbeat which can go along with a heart attack nor a drop in blood pressure, and I think they did an echocardiogram on that same day looking for heart dysfunction.
And in the echocardiogram, the main measure that we're looking for is how efficient is the heart, the left ventricle of the heart as it's ejecting blood.
Normal is between 50 and 70 percent. Mr. Carter's ejection fracture was measured at actually 80 percent. So there really was no indication of any heart dysfunction.
Q. Doctor, with respect to the issue of dehydration, you would acknowledge that Mr. Carter did come in dehydrated?
A. There were a couple of indications that he was dehydrated, even though his blood pressure never fall as a result of it.
His BUN, the blood urea nitrogen, was elevated and that indicates that there was some kidney dysfunction secondary to a drop in circulating volume.
And his urine output, I believe the last day at Imperial was down to 500 cc's, if I recall correctly.
So there was a lower output. The blood test showed a little bit of kidney dysfunction at that point, so yes.
Q. So, Doctor, what effect, if anything, did his long-standing vascular disease have on the BUN value?
A. In diabetics, the larger blood vessels now come into play, the macrovasculature along with the microvasculature we talked about earlier.
So they have less of a reserve in the long run over the decades that they have their disease, they have a much lower reserve so they don't withstand loss of volume as well as the non-diabetic patients would.
Q. And, Doctor, do you have an opinion as to whether the BUN elevation given the fact that Mr. Carter was a diabetic was a significant elevation
A. It really wasn't. Most patients at age 85 with diabetes, I would expect them to have a higher BUN to start with.
But in his case, he had had a normal BUN before this incident. And after he was rehydrated two or three days later, his BUN was right back down to normal again.
Q. Now, Doctor, do you have an opinion as to a reasonable degree of medical certainty as to what you would expect to see clinically in Mr. Carter if his blood sugars were elevated at 5 or 600 for a long time?
A. He would have had the hyperosmolar diuresis I described earlier, his kidneys would have been unable to retain the glucose that was filtered out of the blood so that the urine would have been excessively rich in glucose and he would have made excessive amounts of urine.
He would have had a polyuria, his Foley bag would have filled up very quickly and very often would have to be emptied. His blood pressure would clearly have fallen.
He would have gone into kidney failure and he probably couldn't survive two, three weeks of blood glucose at either 500 or higher.
Q. Did you see any evidence of those types of problems develop in Mr. Carter while he was at Imperial?
A. No, there was nothing in the chart to indicate that.
Q. Doctor, did you - or what, if any, characteristic odor would you expect to find in the patient who had high blood sugars for an extended period of time?
A. I don't know that there's a characteristic odor that goes along with a high sugar.
The urine can become malodorous if it's very concentrated. So later on when you become dehydrated, there would be.
If you're dealing with a Type I diabetic, when they become ketonic, when their body starts to create ketones now in order to feed itself, the ketones have a very distinctive fruity smell and people at the bedside will notice that immediately.
But that's a Type I diabetic. It wouldn't apply here to Mr. Carter.
Q. Now, Doctor, do you have an opinion - or strike that.
The records reflect that Mr. Carter began to suffer a right lower lobe pneumonia and defective decubitus ulcers after February 27th.
Do you have an opinion to a reasonable degree of medical certainty as to whether those problems are related to the hyperglycemia on 2/20/95?
A. I don't believe they are related. The hyperglycemia was corrected and days later he developed these problems.
You know, reading this chart, if he had not had the urinary tract infection on the 20th, he probably would have developed a pneumonia on the 27th and been hospitalized regardless.
Q. And that's the right lower lobe?
A. The right lower lobe pneumonia, correct.
MR. POWER: Actually, Doctor, I have no more questions for you. Thank you.
THE COURT: Is there any cross-examination?
MR. SHAPIRO: Yes, there is.

CROSS-EXAMINATION

BY MR. SHAPIRO:
Q. Good morning, Dr. Danko.
A. Good morning, Mr. Shapiro.
Q. Is it true that you have no particular specialized training or expertise in diabetes?
A. That's correct.
Q. Those medical people who are specialists in diabetes are called endocrinologists, correct?
A. Yes.
Q. And you're not trained in that field, correct?
A. No, sir.
Q. And when you told counsel that you teach at Rush Medical College, am I correct that that is only one day a month?
A. During this part of the year, it's only one day a month. During the other quarters, it's once a week.
Q. Your curriculum vitae lists no research. You're not involved in medical research?
A. No. I'm not.
Q. No lectures listed in your curriculum vitae?
A. I had given the medical students lectures on pharmacology several years ago, but the course director who invited me to give those lectures no longer is the course director so I haven't been invited to do so.
Q. And no lectures to your peers, other doctors, correct?
A. There have been cases where I have given lectures but that's usually informal settings at dinners where I'm invited to talk about certain changes in medications but nothing formal.
Q. And no list of publications, any referee medical journals or textbooks, correct?
A. That's correct.
Q. And when you told counsel that having patients who are diabetics in nursing homes was a very frequent occurrence, isn't it correct that, for example, at the present time you only have three patients total in nursing homes?
A. That's correct.
Q. Now, is it correct that you have been reviewing medical/legal files for lawyers for 20 years?
A. correct.
Q. And you've testified in court exclusively for defense, correct?
A. Well, I actually made a mistake when I said that on my deposition.
The very first time I testified in court was on behalf of the plaintiff, so I apologize for my mistake.
Q. When you testified before, you considered yourself to be representing the defense, correct?
A. In the cases where I represented the defense, yes.
Q. And you've also given various depositions, most of those have been for the defense too, correct?
A. The majority of my calls for help with charts have come from defense attorneys.
Q. Now, I think you said you charge 250 an hour for review and $500 an hour for depositions and trial. And I think you said you had about 12 hours and that was before your deposition, correct?
A. That's correct.
Q. Then how much time did you spend preparing for and giving your deposition?
A. Including the deposition?
Q. Yes, sir.
A. Up to this moment in time, up to trial date?
Q. Up through the deposition.
A. Up through and including the deposition?
Q. Yes, sir.
A. Probably 14 hours.
Q. So that was another 14 hours?
A. No, not - I thought it was inclusive. I'm not understanding your question.
Q. So now you're giving us - you said about 12 hours before you furnished opinions to Mr. Power, correct?
A. Correct.
Q. Then you had to give a deposition on August 10th, correct?
A. Correct.
Q. And you had to prepare for that deposition?
A. That preparation was the full 12 hours I talked about. Up to the deposition, I spent 12 hours on the case.
Q. And then how many hours did you spend in the deposition?
A. I believe that was a two-hour meeting.
Q. And then how much time have you spent in between the deposition up to today?
A. Oh, maybe another eight to 10 hours.
Q. And how did you do your billing for this trial, from the time you leave your house or sitting in the courtroom, how does that work?
A. From the time I'm sitting in the courtroom. I wouldn't - I don't ever charge travel time.
Q. Doctor, is it correct that diabetes interferes with the body's ability to fight infection?
A. Oh, we've known that for a long time, yes.
Q. Now, will you agree that Dr. Saharan did not order Humulin N and if he asked Traci Foster, as she testified, to discontinue the blood glucose monitoring and the Humulin R that he would have committed malpractice?
A. Yes.
Q. Now, you agree that from your review of the records, Dr. Azaran never ordered Humulin N, correct?
MR. POWER: Objection as to the time frame.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. During the admission from February 1st to February 20th at Imperial from your review of the records, will you agree that Dr. Azaran never ordered Humulin N?
A. That's correct.
Q. Now, I take it then that your opinion that Dr. Azaran complied with the standard of care is based solely on the assumption that he ordered blood glucose monitoring and sliding scale Humulin R insulin, correct?
A. Yes.
Q. Am I also correct that in your review of the records, you saw no record that during the admission of February 1st to February 20th that Dr. Azaran ever ordered blood glucose monitoring before meals and before bedtime and sliding scale Humulin R insulin?
A. I believe I saw a telephone order to that effect.
Q. You saw a telephone order to give blood glucose monitoring and sliding scale Humulin R?
A. Yes. And then I believe there's a controversy over who wrote the discontinue notation on the top of those orders.
Q. Can you show me where an order is that doesn't say to discontinue that?
A. No, sir.
Q. So there is no such order, correct?
MR. POWER: Objection.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. You didn't see an order in the chart saying give blood glucose monitoring, give sliding scale insulin for the February 1st admission to Imperial, did you?
MR. POWER: Objection.
THE COURT: Overruled.
THE WITNESS: Okay.
BY MR. SHAPIRO:
Q. Yes?
A. Yes.
Q. Now, would you agree that even if such an order had been given, that the standard of care would require the doctor to check the blood glucose readings to see if the patient was getting Humulin R, whether he was constantly getting Humulin R to see whether he needed to have any medications changed, diet changed, et cetera?
MR. POWER: Objection as to time frame.
THE COURT: Sustained.
BY MR. SHAPIRO:
Q. Would you agree with me that if assuming for the question that Dr. Azaran had ordered simply blood glucose monitoring and Humulin R, that it would have been his responsibility on a periodic basis during that admission to check the results of the blood glucose to see if the patient was receiving - whether his blood glucose was out of the control, whether he was receiving frequent injections of Humulin R or not?
MR. POWER: Objection, compound form and time frame.
THE COURT: Overruled.
THE WITNESS: The physician's responsibility is shared with nursing responsibility. These are orders given to the nurses to monitor the sugars.
BY MR. SHAPIRO:
Q. Excuse me, Doctor. I'm not asking you about the nurses. I'm asking you just about Dr. Azaran.
Did he have a responsibility to check the blood glucose levels to see whether or not the nurses had to frequently give the patient Humulin R?
A. It would depend on his comfort level with the nurses.
If he was not comfortable with them, then yes, he would check to see what they were monitoring and what they were giving.
If these were nurses he knew, if these are nurses that I know and in the case of my patients, I would rely on them if I found them reliable nurses.
Q. Well, Doctor, regardless of the reliability of the nurses, assuming that they did the blood - assuming that they ordered it and that they did it and they had to give the patient Humulin R, wouldn't the doctor need to know how often the patient was receiving the Humulin R so that he could make adjustments to the medication, if necessary?
A. Yes.
MR. POWER: Objection to form and time frame.
THE COURT: Overruled.
THE WITNESS: Yes.
BY MR. SHAPIRO:
Q. And did you see any evidence in the record that Dr. Azaran in the whole 20 days when Mr. Carter was there ever check with the nurses to find out how much Humulin R was being given to the patient on a daily basis?
A. No.
Q. Now, Doctor, as I understand it, as part of your preparation for this case, you were given and you reviewed the deposition transcripts of Dr. Azaran, correct?
A. Yes.
Q. And when you read those depositions, I take it that you formed understandings about the facts in this case that then became part of the basis of your opinion, correct?
A. Yes.
Q. And would you agree with me that they - and you read both of Dr. Azaran's depositions, correct?
A. No, I think I only had one. I think I had Part 2.
Q. Based upon reading Dr. Azaran's deposition, was it your understanding that Dr. Azaran intended to give Mr. Carter Humulin N when he came into the nursing home between February 1st and February 20th?
MR. POWER: Objection as to relevance, his understanding as to Dr. Azaran's -
THE COURT: Overruled.
THE WITNESS: Dr. Azaran in his deposition stated he wanted to continue the insulin treatment that he had already in place at Ingalls prior to the admission.
BY MR. SHAPIRO:
Q. Okay. Doctor, was it your understanding as to Dr. Azaran's intent with respect to providing this patient with Humulin N that Dr. Azaran was under the impression that the Humulin N was to be given?
A. In his deposition, Dr. Azaran kept repeating that he wanted to continue the insulin that Mr. Carter had been receiving.
I don't recall specifically him saying N or R, but he wanted to continue the insulin treatment.
Q. Doctor, do you recall giving a deposition in this case?
A. Yes.
Q. On August 10th, just a few weeks ago?
A. Uh-huh.
Q. Do you recall the following question being asked of you on Page 25 of that deposition at Line 19?
“Question: What is your understanding as to Dr. Azaran's intent with respect to providing this patient with Humulin N?
Answer: My understanding is that he was under the impression that the Humulin N was to be given.”
MR. POWER: Objection, not impeaching as to time frame.
THE COURT: Overruled.
BY MR. SHAPIRO:
Q. Was that question asked of you and did you give that answer?
A. Yes.
Q. And would you agree with me that if it was Dr. Azaran's intention to give Humulin N to this patient and he neglected to order it, that that would be a violation of the standard of care?
A. If it was his intention to give Humulin N, then yes.
Q. Doctor, I believe that you told counsel on - strike that.
Doctor, let me just ask you this flat out. Would you agree that it was probably a combination of the lack of insulin and the developing uterine tract infection that caused Mr. Carter's hyperosmolar hyperglycemic state?
A. It would be a combination of those events, yes.
Q. Will you also admit that with respect to Mr. Carter's dehydration, that it was probably worsened by the lack of insulin given to him while he was at imperial between February 1st and February 20th?
A. Yes, I would.
Q. Would you also agree that in order to rehydrate Mr. Carter, that the doctors at Ingalls had to pass the central line which then caused a pneumothorax?
A. Yes.
Q. Now, you also testified when counsel asked you that when Dr. Azaran saw the patient on February 16th that it was for the purpose of only examining the decubitus ulcer, do you remember that?
A. Yes, I do.
Q. Where does it say that in the medical records?
A. That's all he did was look at the decubitus ulcer.
Q. Do you have Dr. Azaran's note for that day?
A. Not offhand. I believe all he did was write an order to change the treatment.
Q. Can you turn to Page 160 of the Imperial Nursing Home records for the February 1st admission.
A. Yes.
Q. That's Defendant's Group Exhibit No. 1.
A. I have it.
Q. That's Dr. Azaran's note for the February 16th visit, correct?
A. Well, it's not signed by him so I'm not certain.
Q. Assuming that Dr. Azaran has testified that's his note and that's his name of course at the top of it, that note say anything that this was a limited visit or that Dr. Azaran was only called in to just look at the decubitus ulcer, correct?
A. Correct.
Q. In fact, at that visit as reflected by this note, Dr. Azaran assessed the patient's ability to communicate, correct?
A. Correct.
Q. He assessed his status with respect to being in distress or not?
A. Correct.
Q. He assessed his temperature?
A. Correct.
Q. He assessed his lungs?
A. Yes.
Q. He assessed his cardiac function?
A. Yes.
Q. And he made a note that he was going to check his blood count, correct?
A. Yes.
Q. Now, you also testified I believe that you didn't believe that this patient had pneumonia when he came into the hospital, correct?
A. That's correct.
Q. If we could take a look at the Ingalls admission records from February 20th, that admission.
A. Yes, sir.
Q. And specifically calling your attention to Page 211 which is the emergency room record.
A. I have it.
Q. And do you see the note under radiology, Doctor?
A. Yes, I do.
Q. And isn't it a fact that in the emergency room that he assessed the patient as having a left lower lobe pneumonitis?
A. I believe it says infiltrate.
Q. A left lower lobe infiltrate is pneumonia, correct?
A. No, sir.
Q. A left lower lobe infiltrate has got nothing to do with pneumonia?
A. A pneumonia is one possible cause of an infiltrate.
Q. So it's one possible cause of pneumonia or a symptom of pneumonia, correct?
A. An infiltrate is one possible finding on an X-ray that could be caused by pneumonia. It can be caused by several things.
Q. Well, I'd like to call your attention to Page 215 of the records.
A. Same admission?
Q. Yes. And that is the admitting history and physical examination done by Mr. Winter.
A. I see it.
Q. That is the patient's attending physician, correct?
A. Yes, sir.
Q. And is it a fact that this doctor having gone through the entire history and. physical, that his impression for this patient includes left lower lobe pneumonia by X-ray?
A. That's what he concludes.
Q. And he saw the patient, you didn't, correct?
A. That's correct.
Q. Doctor, can you also turn to Page 220 of the chart.
A. I have it.
Q. That is the consultation note of Dr. Hodgihau (phonetic)?
A. Yes.
Q. He's one of the attending cardiologists for this patient?
A. Yes, sir.
Q. He did a consultation on February 23rd, 1995, correct?
A. Yes.
Q. And he indicates in his review of the patient that the last chest X-ray revealed presence of pneumonia in the left lower lobe, correct?
A. That's what he writes.
Q. And then in his conclusions and recommendations, his No. 5 conclusion is pneumonia of the left lower lobe, correct?
A. That's correct.
Q. Now, I believe you also, while we're sticking with Dr. Hodgihau who's a cardiologist on this case, I believe you said that you would be hard pressed to say that there was evidence of myocardial infarction, correct?
A. Correct.
Q. Would it also be fair to say that you would be hard pressed to say that there wasn't evidence of myocardial infarction?
A. No.
Q. Let me ask you this way, Doctor.
Would it be fair to say that you would be very hard pressed to say yes or no on this matter of myocardial infarction?
A. The evidence here is very flimsy for a myocardial infarction. If I had to choose, it would be easier to choose no, there was not. There was no EKG evidence, there was no physiologic evidence at the bedside that was recorded here. The echocardiogram shows a supernormal functioning of the ventricle.
There is just no evidence of it. This one elevated MB and the whole CPK is elevated because of this other muscle that's being damaged, that's very weak evidence. We don't use it anymore today. It was so unreliable, we dropped it.
Q. Doctor, isn't it a fact that Dr. Hodgihau who is the cardiologist on this case listed in his No. 4 conclusion for this patient quote acute nontransmural myocardial infarction?
A. He did list that, yes.
Q. And using the term acute, that means something that just happened, correct?
A. That's correct.
Q. And is it also correct that not only did Dr. Hodgihau, the cardiologist on the case, diagnose acute nontransmural myocardial infarction, but then he went ahead and treated the patient for myocardial infarction, correct?
A. Yes.
MR. SHAPIRO: That's all I have. Thank you.
THE COURT: Any redirect-examination?
MR. POWER: Yes, your Honor.

REDIRECT-EXAMINATION

BY MR. POWER:
Q. Doctor, you told Mr. Shapiro that currently you have approximately three patients in the nursing home. Can you tell me on an average how many patients are in the nursing home?
A. Before this year, probably five, six, seven at any given time.
I've limited my practice now to one single nursing home, so I no longer follow all my patients as they're distributed to very geographical locations. I really tried to cut it down.
Q. Now, Doctor, you indicated that when you're retained by the defense, you represent the defense.
Does that affect your opinions in any way with regard to whether somebody complied with or deviated from the standard of care?
A. No. I've been critical of defense efforts in the past.
Q. In fact, I think you told us that you testified for the plaintiff in the past?
A. Yes.
Q. And in that case, were you critical of the. defense efforts?
MR. SHAPIRO: Objection, your Honor, irrelevant.
THE COURT: With regard to that question, the objection is sustained.
BY MR. POWER:
Q. When you were retained by the plaintiff, did you have a problem criticizing the physician if in fact you felt it was warranted?
A. No, not at all.
Q. Now, Doctor, do you limit your availability to either the defendants or plaintiffs for reviewing records and giving your opinions?
A. Not consciously, no.
Q. Doctor, we talked about this order on February 1 and whether you actually ever saw an order for blood glucose monitoring and Humulin R.
What is your understanding with respect to whether that order was on the chart and later modified with a DC?
MR. SHAPIRO: Objection, no foundation.
THE COURT: Sustained.
BY MR. POWER:
Q. Doctor, did you review the deposition of Dr. Azaran's nurse, Traci Foster, with respect to whether the BGM monitoring and Humulin R were on the chart for any period of time before the DC was added?
A. Yes, I did.
Q. And what did you learn with respect to whether there was an order in place before the DC was placed on the chart?
MR. SHAPIRO: Objection, Rule 213.
THE COURT: Overruled.
THE WITNESS: From my understanding, there was an order to perform the blood glucose monitoring and there was an order for regular insulin.
BY MR. POWER:
Q. And that's at some later date depending on whoever you believe DC was added?
A. Right.
Q. I'm sorry, at some later time?
A. Right.
Q. Now, Doctor, you were asked about a physician's responsibility to review the admitting. orders - excuse me, the blood glucose monitoring orders and the levels.
Doctor, was Dr. Azaran within the standard of care on February 1 to February 20, 1995, if during that time frame he did not ask the nurses for the chart to review them to determine the blood glucose levels during that time frame?
A. As I told Mr. Shapiro, it depends on Dr. Azaran's comfort level with his nurses.
If he hasn't worked with them before and he found them reliable, then asking them to monitor the glucose is an appropriate thing to do.
And typically it's the nurse that calls the physician and says I'm giving insulin four times a day, the sugars are high.
This is taxing on my time to have to administer this often or it's uncomfortable for the patient to receive this so many times.
If one is comfortable with one's nurses, you rely on them. It is after all a nursing home, not a doctoring home.
Q. Now, Doctor, Mr. Shapiro directed you to Page 25 of your deposition where there was a discussion about Dr. Azaran's intent with respect to providing the patient with Humulin N.
I'd like to take a look at Page 25 of the questions before and after that.
A. Okay.
Q. When he talked to you about the questions with respect to Humulin H, did he ever ask you whether the Humulin N was related to the February 1 time frame? It was a general question.
MR. SHAPIRO: Objection.
THE COURT: Sustained.
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