Direct and Cross Examination of Expert Witness Doctor in Nursing Home Lawsuit

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Q. Good morning.
A. Good morning.
Q. Can you please state your full name for the record?
A. I'm Henry Danko.
Q. And are you a physician licensed to practice medicine in the state of Illinois?
A. Yes, I am.
Q. Can you tell us a little bit about your educational background starting with your undergraduate degree?
A. I studied at Northwestern University, I got a bachelor's degree in biology. Then I went down to the University of Illinois in Champagne, Urbana and got a master's degree in physiology and biophysics.
Q. When did you finish your master's?
A. In 1973.
Q. And then what did you do?
A. Then I enrolled in Rush Medical College here in Chicago and graduated in 1976.
Q. And when you completed your medical school training at Rush, what did you do then?
A. I completed a residency training there for three years from 1976 to 1979.
Q. And what was your residency training in?
A. Internal medicine.
Q. Can you tell us what internal medicine is?
A. Well, it's the care of the adult starting at about age 16 or 18, depending when the patient breaks away from their pediatrician.
We do everything for the care of the adult that does not require surgery, obstetrics or psychiatry. We really do everything else.
Q. Does it include the area of geriatric medicine?
A. Yes, it does.
Q. And does it include the area of managing diabetics?
A. Yes, it does.
Q. Either with the use of oral or insulin by shot?
A. That's correct.
Q. Now, Doctor, when you completed your residency training at Rush, did you receive any additional qualifications or certifications?
A. I worked three years at the Bowman Geriatric Facility at Rush. That qualified me to take the qualifying exam for a certificate that was given both by the Board of Internal Medicine and the Family Practice Board. They gave it jointly.
That was the first exam ever given in the area of geriatrics. I took that exam and I passed it.
Q. Before completing your geriatric medicine added qualification exam, did you take the board certification exam for internal medicine?
A. Yes, I did.
Q. Can you tell me, first of all, what it. means to be board certified in internal medicine?
A. In order to take the exam, first you must be board eligible, you must complete an accredited recognized training program and do it satisfactorily, as I fortunately did.
And then you sit for a two-day exam covering about every single field in internal medicine in the greatest depth I've ever seen and walked out of that exam as though two vacuum cleaners were attached to your ears. They want to know everything that you know.
Q. And did you pass the board certification exam?
A. I did.
Q. And, Doctor, what are the - strike that.
After you became board certified, you practiced at Rush University?
A. yes.
Q. And, Doctor, with respect to your board certification, what relevance did it have to your staff privileges?
A. To retain staff privileges after the initial appointment, physicians have to pass their board exam to prove their competence.
Q. Doctor, I think you started to tell us about the geriatric medicine added qualification.
Is there a board certification for geriatric medicine?
A. It's exactly as I described. It's not a full board exam as we have in the various establishments of specialties.
There's some kind of a diplomatic to-do between the Internal Medicine Board and the Family Practice Board.
So they decided to give the exam jointly. And the certificate still reads as added qualification in geriatric medicine.
Q. Is that the highest level of added certification you received for purposes of geriatric medicine?
A. Yes.
Q. and you received that when?
A. 1988.
Q. Doctor, in addition to receiving these qualifications and certifications and practicing medicine, did you also have additional responsibilities in your professional life?
A. Quite a few.
Q. Can you tell us about them?
A. Yeah. I guess my biggest responsibility to date is teaching at Rush Medical College. I've been teaching since I finished my own training and I've taught first- and second-year students, I've done some work with third-year students.
And then on a daily basis my interaction with the residents who practice at Rush-Presbyterian-St. Luke's Hospital which is also a teaching experience.
I've taught the first- and second-year students in a course that's entitled Clinical Concepts and Skills and then Physical Diagnosis the following year.
And essentially we're teaching the students in this course how to examine patients, how to talk to patients, how to come up with diagnostic schemes, how to formulate ideas of disease of treatment from interacting with the patient in the office.
Q. Are you still an assistant professor at the Rush Medical College?
A. Yes, I am.
Q. Doctor, in addition to teaching at Rush, do you also hold committee memberships at Rush?
A. I'm on several committees. It's sort of expected of us to volunteer. If we don't volunteer, the chairman of the committee will call up and ask you to volunteer.
I think the longest-serving committee I've been on now is the Pharmacy and Therapeutics Committee where we meet monthly to discuss new medications, old medications, replacement of medications.
I'm on the subcommittee for that committee to discuss what's in the pipeline, what's coming up from the drug companies that's not even been discussed yet either in the hospital or in Wall Street.
I'm also on a committee now that will look at promotion of faculty members. I think those are the two active committees I'm serving on currently.
Q. I'm sorry?
A. Those are the only two that I'm actively serving on now.
Q. Doctor, were you involved in the end of life issues committee?
A. Yes, I was.
Q. Can you tell us what that committee dealt with?
A. It's very difficult for physicians to deal with the end of life. There's really no formal training in medical school, as least when I went. I think now there are some formalized teachings.
The hospital grappled with it back in the late ‘70s or early ‘80s. I forget when that committee met. And we tried to come up with guidelines to help physicians deal with patients who were dying, how to deal with family members, how to talk with them, what kind of documents we had to generate or sign in order to comply with the law and comply with morals and ethics.
Q. Were one of the documents that you dealt with commonly referred to as a DNR order?
A. The DNR order had always been there. It was matter of how to get there.
Q. Can you, first of all, tell us what a DNR order is?
A. A DNR order stands for Do Not Resuscitate. In itself it seems straight forward, but it also has many nuances, what is resuscitation.
Generally when a patient's condition is terminal or pre-terminal, when further action would be deemed futile, it would be cruel to try to keep the patient alive at that point.
And if there's a clear understanding among all the treating physicians or at least a consensus, if there's an understanding with the family members that further actions will really not do any good, nurses are involved also of course in this decision making, then we can come to an agreement that should the patient suffer either a respiratory arrest or a cardiac arrest, that no heroic measures would be instituted. We would let the patient die a natural death.
The nuances of course include, you know, what is resuscitation. When a patient comes in with a very low blood pressure, badly dehydrated or bled very profusely, then we talk about fluid resuscitation, do you pour in massive amounts of fluid in a patient like that.
We talk about intubation if the patient is not breathing well, do you want to put a tube into that patient's airway and mechanically ventilate the patient. That is a form of resuscitation.
So when we talk about DNR, Do Not Resuscitate, sometimes we add to that do not intubate, sometimes we add do not use blood pressure-raising medications, depressors and family members will occasionally lead us to also say don't put any feeding tubes in, don't use any more IV fluids, just let the patient do whatever the patient can.
Q. In this case there was no evidence - strike that.
You would not include don't give insulin as something that would be applicable to a DNR, correct?
A. No absolutely.
Q. And you wouldn't talk about not feeding a patient as part of a DNR order, correct?
A. If the family members requested no feeding to take place other than oral feeding, that we not put feeding tubes in either through the nose or through the stomach surgically, then of course.
Q. There's no evidence of that in this case, right?
A. I think Mrs. Carter did ask that no feeding tube go in initially.
Q. Eventually there was a feeding tube put in?
A. Eventually there was, yes.
Q. And that was on the 23rd or 24th of February?
A. I believe so.
Q. Now, Doctor, you also served on the Infectious Disease and Sepsis Control Committee between 1982 and 1987?
A. Yes.
Q. Can you tell me what that committee dealt with?
A. We were looking at patterns of infections particularly in the hospital to see whether we had any problems with infectious control, really for outbreaks of specific types of infections on various units.
We had a clustering of staph infections or tuberculosis outbreak, just to make sure that those who take care of patients were not doing harm.
Q. Now, Doctor, in addition to those appointments, you were also a member and are a member of certain associations, professional associations?
A. Yeah, the AMA and the Illinois Society of Medicine and the Chicago Society of Medicine, all the usual, the American Geriatric Society.
Q. And, Doctor, were you - strike that. Are you currently - strike that. Were you the medical director of Hospice of Illinois between 1997 and 1999?
A. Yes, I was.
Q. Can you tell me, first of all, what Hospice of Illinois is?
A. Hospice of Illinois is a for-profit group that takes care of patients who are deemed hospice appropriate, patients whose physicians and family agrees that the life expectancy is six months or less.
Hospice care is provided for by the Medicare Act, it's paid for by Medicare. And essentially it's a humane way of approaching a dying patient. It's taking care of all their needs, all their physical needs, take care of all their symptoms, their fears, pain, nausea, shortness of breath, alleviating all symptoms of their illness, but trying to avoid needless hospitalizations, needless procedures, things that would possibly prolong their lives but at the cost of their comfort.
Q. Doctor, in your opinion was
Mr. Carter hospice qualified as of January 13th, 1995?
MR. SHAPIRO: Objection, Rule 213.
THE COURT: Sustained.
Q. Now, sir, I asked you to review certain - strike that.
In your actual care and treatment of patients, you have interacted with patients since you finished your residency training?
A. Yes.
Q. And can you tell me are you a part-time clinician or a full-time clinician? Can you tell me on average how many patients you see?
A. I'm a full-time clinician. I have a solo practice. I'm all alone in my office.
I'll see between 10 to 20 patients a day in the office and an average of four, five patients in the hospital per day. I also have a small group of patients at one nursing home right now.
Q. Can you tell us generally what the makeup of the patient population is between the geriatrics versus adults?
A. My practice started off as largely geriatrics when I finished my training, but now with the advent of managed care, all the contracts that the hospital and I have had to sign with insurance companies, they're sending me younger patients as well.
So probably the mix has gotten younger in the last three or four years. My patients will range from 16 to - I think I have a 95-year-old right now in my practice.
Q. Doctor, have you had experience in treating nursing home patients who are diabetic?
A. Yes.
Q. Can you tell me on average how often you see that type of patient in your practice?
A. You know, the onset of diabetes grows with age. In the young population, I got about 5 percent. Classically it was 5 percent. Recently it's actually gone up to well over 6 percent now.
Once we approach age 70, you have about 50 percent incidence of diabetes. By the time the patient reaches the age of 80, you're well over 60 to 70 percent. So it's a very frequent occurrence.
Q. Doctor, have you had experience in treating diabetics who are bedridden in nursing homes?
A. Yes.
Q. Can you tell me how often that has occurred in your practice?
A. Not that often. The bedridden patient, once they become bedridden, their life expectancy drops off dramatically.
Q. Doctor, are there special concerns with geriatric patients who are diabetics?
A. The usual concern. They have an accelerated rate of onset of disease. I think I described earlier in my deposition the fact that diabetes can be seen as an acceleration of all aging processes.
In the diabetic, we see the onset of heart attacks sooner, strokes come on sooner, kidney failure certainly comes on sooner, cataracts occur at a younger age in diabetics. It really is an accelerated aging.
So treating any diabetic, you know, we look for these diseases much sooner. A 40-year-old diabetic with chest pain, we take that very seriously as opposed to an ordinary patient - a 40-year-old patient with chest pain is very unlikely to be heart disease, but a diabetic, you know, too many times it is heart disease.
Q. Doctor, with respect to diabetes, what effect does it have on the patient's microvascular system?
A. The microvasculature, the arterioles, not the arteries, but the arterioles are affected primarily. They are obstructed, they are stenosed.
And that is one of the leading factors in the disease process in diabetes is that the arterioles when they become obstructed will manifest themselves as eye disease, kidney disease, the skin will break down very easily.
There's very little blood supply to fatty tissue to start with and when the arterioles of fatty disease break down, there's just a breakdown of tissue there.
Q. Now, Doctor, I want to stop you for a second. You said not arteries but arterioles. Can you tell me what the difference is?
A. The arteries are the large vessels where we can actually feel a pulse, put a finger over your own radial artery, that's an artery.
When it gets smaller, when it branches down again, you really don't feel the pulse anymore, when it becomes small enough, we call them arterioles.
Q. Now, Doctor, do the effects of diabetes generally develop acutely and quickly, or does it develop over time?
A. No, it's a slow onset. It's a gradual erosion of functions.
Q. And can you tell me why that is?
A. The changes in the blood supply, the changes in the nerve function, the peripheral nerves. It all occurs very gradually with the ravages of diabetes.
Q. Now, Doctor, did I ask you to become involved in this case and review records and certain depositions and provide me with your opinions?
A. Yes.
Q. And you are charging me for your time, you have charged me for your time to do that?
A. I will.
Q. And, Doctor, can you tell me what your fees are with respect to your involvement in reviewing the records, in providing a deposition and testifying at trial?
A. Reviewing records, my fee is $250 an hour, and for both depositions and for court testimony, it's $500 an hour.
Q. Now, Doctor, can you tell us what records you reviewed in this case before developing the opinions with respect to the care and treatment rendered to Mr. Carter during the time frame at issue?
A. I looked primarily at his admission at Imperial Nursing Home from February 1st to February 20th.
I looked at his record at Ingalls Hospital. I think he was transferred from Imperial to Ingalls. I looked back at the records -
Q. That would be the February 20th admission?
A. February 20th to I think March 17th.
Q. Right.
A. I looked back at his Ingalls admission in January, late January, I think it was the 19th and also when he was Imperial for a few days before that, January 13th through the 18th.
And then you asked me to look at the depositions of several physicians.
Q. Did you also look at the Glenwood Terrace Nursing Home records and the St. James hospitalization from September 1984?
A. Yes, I did.
Q. And you looked at the deposition of my client, Dr. Azaran?
A. Yes, I did.
Q. And you looked at the deposition of Dr. Fine?
A. Dr. Fine's also, yes.
Q. And you also looked at the deposition of Traci Foster but didn't come to opinions as to who was right and who was wrong as to the events surrounding February 1, is that fair?
A. That's correct. And also a deposition of Dr. Sing I believe.
Q. And Dr. Santos?
A. And Dr. Santos, yes.
Q. Now, Doctor, can you tell me approximately how much time you spent reviewing all those materials before developing an opinion in this case?
A. I think about 12 hours.
Q. And, Doctor, after reviewing all of those records, did you arrive at an opinion as to whether Dr. Azaran complied with or deviated from the standard of care between his first involvement of January 13th, 1995, and the end of his involvement in this case February 1, 1995 - excuse me, February 20th, 1995?
A. Yes, I did.
Q. Now, Doctor, we'll talk about those opinions in a minute.
Is hyperglycemia and hypoglycemia known issues with respect to diabetes?
A. Yes, they are.
Q. Can you tell me what the difference is and potentially how the complication are associated with each and every one of those conditions?
A. Hyperglycemia, a high blood sugar, can lead to many pertubations, disturbances in the normal functioning of the human body.
If it is extraordinarily high, you can have as osmotic diuresis. That's the first thing that a patient will notice. An osmotic diuresis is a profuse production of urine. The kidney is supposed to return sugar from the bloodstream after it filters it back into the bloodstream.
But when confronted with a very high blood sugar, some of it spills in the urine and the kidney is unable to retrieve all of it and the sugar will take water with it so that the patient will produce a very large volume of urine, they will urinate excessively and generally also develop a thirst and that's usually the first presentation of diabetes.
If the patient is allowed to drink naturally, they will function normally for a given time. If for any reason fluid is withheld, then the disturbance will lead to dehydration and loss of blood pressure, kidney failure and then cascading, going onward from there.
There are many, many other manifestations of hyperglycemia. When the blood sugar gets high, the pancreas is then stimulated to produce more insulin.
If the pancreas can produce insulin, it's a Type II diabetes, then you'll set the condition of a high insulin level also known as hyperinsulinemia. The high circulated insulin level itself is also harmful to the body.
Q. How's that?
A. It appears that the higher the insulin level is, the more nerve damage occurs and perhaps even more blood vessel damage occurs.
So the reaction of the body to the high glucose level which is by producing more insulin is also deleterious.
Some of the newer treatments we have today which were not available in 1995 - .
Q. Let's just talk about the 1995 treatments, Doctor.
And if I could ask you to keep your voice up a little bit. I'm having a little trouble hearing you and I want to make sure that I can hear everything you have to say.
Doctor, I cut you off. You didn't talk about hypoglycemia.
A. Hypoglycemia is a low blood sugar. When the sugar drops too low and, again, body tissues are going to be disturbed, primarily muscle tissue which uses the majority of our glucose or metabolism for energy, so there will be a weakness.
If the hypoglycemia is allowed to go further, then even the brain will start to malfunction. The brain is the only tissue in the body that actually does not need insulin in order to utilize glucose. Every other tissue does.
It's a protective mechanism. So that if there's a very low blood sugar, the body naturally shuts down its own insulin production and so that the muscles don't get either insulin or sugar, but the brain gets whatever sugar is left over.
Q. Can hypoglycemia or does it have any risks associated with it including death?
A. Oh, absolutely.
Q. Now, Doctor, are diabetics at risk generally for any problems in addition to the general population if they're bedridden?
A. Well, they're at risk whether they're bedridden or not.
Q. I guess maybe it's a poorly-worded question.
With a bedridden patient, what additional risks do diabetics have in the general population with respect to the development of bed sores or other complications?
A. Okay. In general, diabetics are predisposed to infection and they're predisposed to vascular insufficiency.
Put that kind of a patient at bed, at bed rest who's somebody who just cannot move about himself, now you're dealing with lungs are not expanding, so you're dealing with a risk for pneumonia, you're dealing with bed sores, the pressure of the body itself compresses the blood vessels, squeezes the blood out and does not allow blood flow in the compressed area.
If the patient has any mental problems or neurologic problems or is drugged or tied to a bed, if the patient cannot move or cannot feel the pain, as happens with diabetics, their nerves malfunction so they don't feel pain the way most of us do, then you are at great risk for bed sores.
Patients like that, it's almost impossible to prevent - all the mechanisms we have in place today still don't prevent bed sores. You have compression of these blood vessels, blood is not getting through there.
The ischemic tissue, the tissue that's not getting oxygen will break down when a patient is moved by the nursing staff, by family members, under their own volition.
The shearing forces of the body rubbing against the bed or bed clothes or against the side rail can cause tissue damage and because of their poor vasculature, they just won't heal.
Q. When you say their poor vasculature, what do you mean?
A. The blood supply is diminished because the blood vessels are so narrow.
Q. And what does the diminished blood supply, what effect does that have on the ability of the body to heal once it develops a bed sore?
A. It makes it almost impossible to heal.
Q. Now, Doctor, are the bedridden diabetics at risk for any additional problems? I think you mentioned pneumonia and bed sores.
If you add to that an in-dwelling Foley catheter to a bedridden patient, what additional risks are attendant to that Foley catheter?
A. Clearly having any instrument inside the body predisposes that part of the body to infection.
If you break the barrier between the outside and the inside, whether it's with an IV line or a Foley catheter in the bladder, the diabetic because of their nerve problems and neuropathy will also lose control of their bladder a lot sooner.
So they are unable to void voluntarily and empty completely. So they are much more likely to require a Foley catheter, an in-dwelling catheter of the bladder. And, again, that's an avenue for infection.
Colonization of the bladder, the presence of bacteria in the bladder is universal when the catheter is used.
Infection where the body is not responding to an overwhelming presence of bacteria with white count with a fever, that is a consequence that comes later.
Q. Doctor, are you telling me that everyone who has a Foley has bacteria in their system?
A. Pretty much, yes, in their bladder. I don't know what you mean by system.
Q. I'm sorry, in their bladder?
A. Yes.
Q. And that's regardless of whether or not they're infected?
A. Correct.
Q. Can you explain that to us?
A. Our bodies are colonized all over with bacteria, but we don't consider ourselves infected. Our hands have bacteria, our mouths, every mucous membrane has bacteria. Our colon is full of bacteria.
The urine of a patient with a catheter in is going to have bacteria in it. Our stomach has bacteria. Our small bowel has a beneficial bacteria we cannot live without.
Q. Doctor, in reviewing Mr. Carter's case, what did you discover about his medical condition before January 13th, 1995?
A. Before January 13th, I believe he was a man with severe Alzheimer's disease. The description was that he was not communicative, his speech was really gibberish, he was hard to direct and redirect by the nurses at the nursing home.
He started somewhere around that time having problems with his gait, I believe he started stopping, he was losing balance or stooping forward to regain some balance.
And I think shortly thereafter he began to fall. There was actually a history of falls before then. I remember reading something about nurses wanting to put safety devices on Mr. Carter. There was some passage that the wife didn't want him tied down, but the nurses were afraid of him falling, but there were several falls before that and subsequent to that also.
Q. And eventually did he suffer a stroke?
A. It appears he suffered a stroke, yes, probably more than one, but at least one.
Q. Was that about December 10th or December 14th, 1994?
A. December or January.
Q. Was that the December admission to St. James Hospital?
A. Yes, I believe so.
Q. Doctor, from the time he suffered a stroke until January 13th, did the records reveal that he had suffered any urinary tract infections?
A. I believe there was at least one incident recorded of what's called urosepsis, infection of the bladder.
Q. And what's the difference between a urinary tract infection and urosepsis?
A. Urosepsis is really used a little too loosely by most young physicians I come in contact with.
Urosepsis really implies that the individual is quite ill, the high fevers, profuse sweating, you know, frequent uncontrolled urination, a painful urination sometimes associated with a high white count, a drop in blood pressure.
A urinary tract infection as many of us have had experience with either personally or family members, a little burning when you urinate, frequent urination, nighttime urination, three days of pills and it's cleared up.
Q. And was there any evidence of pneumonia between December 10th and January 13th?
A. I don't remember that.
Q. Now, Doctor, was Mr. Carter dehydrated at all during his admission to St. James Hospital?
MR. SHAPIRO: Objection, irrelevant.
THE COURT: Overruled.
THE WITNESS: I don't remember dehydration.
Q. And, Doctor, with respect to the status of his vasculature, did it appear to you based on the notes that his vasculature was compromised in December of 1994?
MR. SHAPIRO: Objection, leading.
THE COURT: Sustained.
Q. What did you notice, if anything, about the status of his vasculature between December 10th, 1994, and January 13th, 1995?
A. I think he already had skin breakdown on his buttocks, so I would assume from that he's already had vascular compromise.
He also was described as having Alzheimer's disease. I don't know how rigorously that diagnosis was arrived at.
Reading these records over the three, four-month period there was a decline in his mental function and it appeared to me at least in this little snapshot of this man's life appeared to be a step-wise progression.
Alzheimer's disease, the diminution of cognitive function, it's a very gradual downhill course in a dementing process that is caused by multiple strokes.
We see more of a step-wise where there's a sudden drop off and a leveling and then another sudden drop off versus a slow -
MR. SHAPIRO: Your Honor, objection, Rule 213.
THE COURT: I'll sustain it as to the narrative summation.
Q. Doctor, how would you characterize his Alzheimer's as of December 1994?
A. In December of 1994, Mr. Carter was not given credit for speaking. He was already described as having lost weight. His gait was compromised, he was falling.
So he was already an advanced case of dementia. Again, I don't know that he had true Alzheimer's, but he had a dementing process.
Q. Doctor, based on your review of the December 1994 St. James Hospital records, did he also have spinal stenosis or something that happened to his neck?
A. Yes. After one of his falls when he developed weakness in both legs, there was an investigation of his cervical spine and there was some evidence that he had stenosis of the spine, the bone had encroached upon the spinal cord, there was some disks out of place also that were also compressing the cord. So there were several reasons for him to develop weakness at that point.
Q. From the time he was diagnosed with this bone compressing the cord, did you ever see any evidence that he was able to walk again?
A. No, I did not.
Q. Now, Doctor, what did you notice, if anything, about his diabetes management during that admission?
A. It really did not seem very remarkable. His sugars were kept under relatively good control, the ones that I saw and I don't remember specifically, but there was just nothing extraordinary.
He was being treated with a long-acting insulin, the NPH insulin and there was just nothing remarkable about it.
Q. During that admission, did he also receive some Humulin R sliding scale?
A. Yes.
Q. And, Doctor, based on your review of the chart, despite those medications, did he develop the problems that we just talked about?
MR. SHAPIRO: Objection, leading.
THE COURT: Sustained.
Q. What problems did he develop during that admission despite the fact that he was on N and R?
MR. SHAPIRO: I just object to what admission we're talking about.
THE COURT: Sustained.
Q. Dispute being on Humulin N and Humulin R, what problems did Mr. Carter develop, if any, during the December 10, 1994, admission to St. James?
A. Well, his ulcers got worse. I believe he needed more debridement. There was some mention of some redness and dryness of his heels which would qualify him as a Stage I decubitus ulcers of his heels.
His mental status, just, you know, did not improve. It gradually worsened. He had at some point been self-feeding and then needed help being fed. So despite being treated, there was still some evidence of deterioration.
Q. Now, Doctor, do you have an opinion to a reasonable degree of medical certainty as to whether Mr. Carter suffered any of these problems as a result of his diabetes and the problems we talked about before January 13th, 1995?
A. 1 wouldn't know.
Q. Well, from your review of the records between December 10th, 1994, and January 13th, 1995, do you have an opinion as to whether Mr. Carter suffered any of the above problems that we just talked about as a result of his diabetes?
MR. SHAPIRO: Objection, asked and answered. He said he didn't know.
Q. Go ahead.
A. It appears that these problems continued despite being treated adequately for diabetes.
Q. Did you - strike that.
Doctor, can you tell me generally what relevance does food intake have for the need for insulin whether it's long-acting or short-act ing?
A. You know, food will contain carbohydrates, starch, sugar, all the same substance essentially and as that's absorbed into the bloodstream, we would need insulin in order to move it from the bloodstream into the tissues. We cannot move it out of the bloodstream without insulin.
So as food is absorbed, as the starches are broken down into the individual glucose molecules, we need insulin to utilize it.
Q. And, Doctor, if food intake is decreased in the absence of any other problems, what does that do to the need for insulin?
A. Well, then you have to reduce either the production of insulin within the pancreas or the administration of insulin.
Q. Doctor, what can occur if too much insulin is in the body when food intake is low?
A. Then the individual becomes hypoglycemic, the blood glucose drops, the nerve tissues, muscle tissue and eventually brain tissues can begin to starve.
Q. Doctor, there's been some discussion about Type I or Type II diabetes.
Can you, first of all, tell us what a Type I diabetic is?
A. Type I diabetic tends to be a younger patient, as young as ten years old, even younger. These people have essentially a complete shutdown of production of insulin in their pancreas. They must have insulin to survive. Without it, they won't live.
Type II diabetes is a much more common form of diabetes that we see in the adult. The onset tends to be in the third, fourth, fifth decade of life and then just continues on and accelerates after that.
Type II diabetics have either an insufficient production of insulin in their pancreas or their tissue where the insulin acts to allow glucose into the tissue as a resistance to the effect of the insulin. It's insulin resistant.
If you think of insulin as a key to a lock, then Type I is not enough keys or no keys being produced and Type II, there are not enough keys and their locks are rusty.
Q. Doctor, is a Type II diabetic in your opinion someone who is insulin dependent?
A. Not insulin dependent per say. There are some Type II diabetics who are better treated with insulin, but they do survive without it.
They do produce their own insulin and if you can stimulate either more production of insulin from their pancreas through one group of medication or can reduce the resistance to the insulin with another group of medication, then they should not need supplemental insulin.
Q. Doctor, did you arrive to an opinion to a reasonable degree of medical certainty as to which classification Mr. Carter fell in?
A. He clearly falls as a Type II.
Q. In your opinion, was he insulin dependent as a lifeline to sustain life?
A. No, I don't believe so.
Q. What do you base that on?
A. I believe that he went without insulin from the 1st of February to the 20th of February at Imperial and he survived.
Q. Doctor, if he was a Type I diabetic, would he have been able to survive?
A. Oh, absolutely not.
Q. Now, Doctor, I'd like to turn your attention to the January 13th to January 18th admission to Imperial, which I believe you have in front of you.
A. Yes, sir.
Q. And simply refer to the discharge transfer sheet to Ingalls.
First of all, was Mr. Carter on Humulin N 22 units while he was at Imperial between January 13th and January 18th?
A. May I look at the record?
Q. Sure. Take your time.
A. Yes, he was.
Q. And can you tell us the stage he was in at the time of the transfer from Imperial to Ingalls at the end of that short admission?
A. Mr. Carter had fever of unknown origin, he had had that CVA and I believe that was the reason for the admission, the fever.
Q. Was it your understanding that he was diagnosed as having a urinary tract infection in the hospitalization at Ingalls after the January 18th transfer to Ingalls?
A. Yes, sir.
Q. And, Doctor, did that occur when he was on or off Humulin N?
A. He was on Humulin N at the time.
Q. Doctor, do you have an opinion to a reasonable degree of medical certainty whether 22 units of Humulin N was appropriate to manage his diabetes at that time between the 13th and the 18th?
A. It appeared to have been appropriate.
Q. Now, Doctor, to a reasonable degree of medical certainty - you were aware that Dr. Azaran was Mr. Carter's treating physician during that January 13th admission?
A. Yes.
Q. Do you have an opinion to a reasonable degree of medical certainty as to whether Dr. Azaran complied with the standard of care in continuing the admitting orders to Imperial for Humulin and 22 units during that admission?
A. I believe he complied with all the standards, sure.
Q. Doctor, once he was transferred to Ingalls on N, if you look next to the February 1 transfer sheet back to Ingalls or - excuse me, back to Imperial.
If I can direct your attention to Defendant's Group Exhibit 1. It should be the Imperial Nursing Home records from the February 1 admission.
A. Okay.
Q. And I'd ask you to look at the transfer sheet.
A. Okay.
Q. Which I believe is stamped at Page 140 and 142.
A. Yes, I have it.
Q. What did you note with respect to the type of insulin and coverage he was on when he came back to Imperial on February 1?
MR. SHAPIRO: Objection to the question, what he was on.
THE COURT: Sustained.
Q. What type of insulin or blood glucose monitoring orders were in effect on February 1 at the time of transfer from Ingalls to Imperial?
MR. SHAPIRO: Objection, it's to time frame and fact.
THE COURT: Sustained.
Q. On February 1, based on that transfer order, can you tell me what orders were in effect for insulin coverage for Mr. Carter at the time of his transfer?
MR. SHAPIRO: Objection.
THE COURT: Sustained.
Q. Doctor, can you tell me what you noted, if anything, about the transfer sheet with respect to the discussion of insulin coverage or blood glucose monitoring on that sheet on Page 142?
A. On Page 142, the insulin has been changed to insulin R, the faster-acting insulin and monitoring has now been ordered to be done four days a time, once before each meal and once before bedtime.
Q. And, Doctor, do you have an opinion to a reasonable degree of medical certainty as to whether that order on February 1 complied with the standard of care for the management of Mr. Carter's diabetes on February 1 when he was admitted to Imperial?
MR. SHAPIRO: Objection. It's not an order. The form of the question.
THE COURT: Overruled.
THE WITNESS: I believe it's quite adequate, yes.
Q. And, Doctor, had those orders been carried out the entire admission to Imperial, do you have an opinion to a reasonable degree of medical certainty if those were the orders and those were instituted whether Dr. Azaran complied with the standard of care for the management of the diabetes during that admission?
A. Yes, he would have.
Q. Doctor, what, if any, orders did he have with respect to diet based on the transfer sheet?
A. The diet that was ordered on the transfer sheet was a puree diet with a low sodium content and low salt content.
Q. And, Doctor, based upon the physician's order sheet from February 1, what information did you obtain with respect to the calorie counts and the type of feeding that was to be instituted for Mr. Carter at Imperial during that admission?
A. Dr. Azaran ordered a calorie count to be measured.
Q. And was that - when was that ordered?
A. February 1.
Q. And, Doctor, can you tell us, and I believe it's in front of you, what did the calorie count show for his intake when he was readmitted to Imperial for the days that the calorie count would be done?
A. Do you know offhand what page that's on?
Q. I don't believe you're going to find it on the numerical pages. I believe it's -
MR. POWER: If I may have a moment, your Honor.
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