Free Motion to Preclude - District Court of Connecticut - Connecticut

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0001 1 IN THE UNITED STATES DISTRICT COURT 2 FOR THE DISTRICT OF CONNECTICUT 3 VOLUME I 4 ------------------x : 5 LAURA GUIGLIANO, as ADMINISTRATOR of the ESTATE of MICHAEL GUIGLIANO, : 6 DECEASED, and LAURA GUIGLIANO, Individually : 7 Plaintiffs, : 8 vs. : 9 DANBURY HOSPITAL, ET AL, : 10 Defendants. : 11 - - - - - - - - - - - - - - - - - - x 12 3:02 CV 718(RNC)(DFM) 13 14 Deposition of MICHAEL B. TEIGER, M.D., 15 taken pursuant to the Federal Rules of Civil 16 Procedure 26(B)(4)(a), at the offices of 17 Michael B. Teiger, M.D., 1000 Asylum Avenue, 18 Hartford, Connecticut, before Michelle E. 19 Pappas, License #00081, a Notary Public in 20 and for the State of Connecticut, on Tuesday, 21 February 28, 2006, at 8:50 a.m. 22 23 24 25 0002 1 APPEARANCES 2 THE LAW FIRM OF JOSEPH LANNI, P.C. 3 Attorneys for the Plaintiffs 138 Chatsworth Avenue, Suites 6 - 8 4 Larchmont, New York 10538 By: JOSEPH LANNI, ESQ. 5 Tele: (914) 834-6600 6 RENDE, RYAN & DOWNES, LLP 7 Attorneys for the Apportionment Defendant and Third-Party Defendant

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202 Mamaroneck Avenue White Plains, New York 10601 9 By: MICHAEL F. GRADY, ESQ. Tele: (914) 681-0444 10 11 NEUBERT, PEPE & MONTEITH, P.C. Attorneys for the Defendant Danbury Hospital 12 195 Church Street, 13th Floor New Haven, Connecticut 06510-2026 13 By: ERIC J. STOCKMAN, ESQ. Tele: (203) 821-2000 14 15 RYAN, RYAN, JOHNSON & DELUCA, LLP Attorneys for the Defendants John Borruso, M.D. and 16 Danbury Surgical Associates 80 Fourth Street 17 Stamford, Connecticut 06905 By: BEVERLY HUNT, ESQ. 18 Tele: (203) 357-9200 19 HALLORAN & SAGE, LLP 20 Attorneys for the Defendant Joseph Catania, M.D. One Goodwin Square 21 Hartford, Connecticut 06103 By: TIMOTHY GRADY, ESQ. 22 Tele: (860) 522-6103. 23 24 25 0003 1 STIPULATIONS 2 3 IT IS HEREBY STIPULATED AND AGREED by and 4 between counsel representing the parties that each 5 party reserves the right to make specific objections at 6 the trial of the case to each and every question asked 7 and of the answers given thereto by the deponent, 8 reserving the right to move to strike out where 9 applicable, except as to such objections as are 10 directed to the form of the question. 11 IT IS FURTHER STIPULATED AND AGREED by and 12 between counsel representing the respective parties 13 that proof of the official authority of the Notary 14 Public before whom this deposition is taken is waived. 15 IT IS FURTHER STIPULATED AND AGREED by and 16 between counsel representing the respective parties

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17 that the reading and signing of the deposition by the 18 deponent is not waived. 19 IT IS FURTHER STIPULATED AND AGREED by and 20 between counsel representing the respective parties 21 that all defects, if any, as to the notice of the 22 taking of the deposition are waived. 23 Filing of the Notice of Deposition with the 24 original transcript is waived. 25 0004 1 (December 28, 2005, report marked 2 Plaintiffs' Exhibit 1 for identification.) 3 (Vanessa Saipher Incident Report marked 4 Plaintiffs' Exhibit 2 for identification.) 5 (Code 99 Flow Sheet marked Plaintiffs' 6 Exhibit 3 for identification.) 7 (Emergency Code Log marked Plaintiffs' 8 Exhibit 4 for identification.) 9 (Transportation Scheduling Sheet marked 10 Plaintiffs' Exhibit 5 for identification.) 11 MR. STOCKMAN: Just at the outset, the 12 Doctor has patient issues, as doctors will, 13 patient issues are encountered from time to 14 time, and we've agreed, if necessary, we'll 15 bring the Doctor back for the resumption of 16 the deposition if we do not finish today for 17 a time convenient to everyone. 18 MR. LANNI: Just to add to that, it's my 19 understanding that Dr. Teiger has to break 20 the deposition at 11 a.m., thereabouts? 21 THE WITNESS: Unfortunately, my life 22 goes on despite this, but I'll be here to do 23 the best I can. I thank you for all of your 24 patience and indulgence and apologize if you 25 have to drive up here again, but we do pay 0005 1 for parking, if that helps. 2 MR. LANNI: And then we'll do our best 3 to reschedule you at a time that's mutually 4 convenient for all parties. And, 5 furthermore, it's been agreed that should 6 Plaintiff need to submit a motion to the 7 Court extending the deadlines with regard to 8 depositions and other matters in this case, 9 that all parties will consent to such a 10 motion. Any problem with that gentleman and

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11 lady? 12 MR. M. GRADY: No. 13 MR. STOCKMAN: Generally speaking, no, I 14 have no problem applicable to discovery 15 deadlines. 16 MR. LANNI: Okay. 17 MICHAEL B. TEIGER , M.D., 18 called as a witness, having first been duly sworn 19 by Michelle E. Pappas, a Notary Public in and for 20 the State of Connecticut, was examined and 21 testified as follows: 22 DIRECT-EXAMINATION 23 BY MR. LANNI: 24 Q. Good morning, Dr. Teiger. 25 A. Good morning. 0006 1 Q. My name is Joseph Lanni, I'm the attorney for 2 the Guigliano family. I'm going to be asking you some 3 questions today concerning your expert opinions in the 4 case of Guigliano versus Danbury Hospital, et al. Any 5 question that I ask you that you do not understand, 6 please let me know, I'll be more than happy to rephrase 7 the question to make it -- more than happy to rephrase 8 the question for you so that you can better understand 9 it. Okay? 10 A. Thank you for that. 11 Q. Sure. And please, I'm going to ask you to 12 verbalize all your responses because the court reporter 13 can't take down any nods of the head or shake of the 14 head or any type of gesture, so I'll ask you to 15 verbalize all your responses. 16 A. I'll be happy to do my best. 17 Q. Okay. Moreover, we have marked a number of 18 items as exhibits for today's deposition. Exhibit 1 is 19 the original of your report concerning your expert 20 opinions in this case dated December 28, 2005. And 21 Exhibit 2 is an incident report of a Virginia Saipher 22 concerning the events in the CT scan suite of February 23 17, 2001. 24 Exhibit 3 is the Code 99 flow sheet 25 concerning the cardiopulmonary arrest of February 17, 0007 1 2001. Exhibit 4 is the emergency code log for Danbury 2 Hospital pertaining to the month of February 2001. And 3 Exhibit 5 is what's called the Transportation 4 Scheduling Sheet for the date of February 17, 2001.

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5 Please feel free to look at the exhibits that 6 I have identified to you to provide me with answers to 7 any of my questions. Moreover, please feel free to 8 refer to any of the materials that you have reviewed in 9 this case to provide me with answers to my questions. 10 Okay, sir? 11 A. Thank you for that introduction. I'd like to 12 comment that I believe I'm familiar with all of the 13 Plaintiff's exhibits except what is marked Plaintiffs' 14 Exhibit 2. 15 Q. Which would be the Virginia Saipher incident 16 report? 17 A. That's correct. I don't believe I've had an 18 opportunity to read this report yet, although, it is 19 short and I'll be happy to do that today. 20 MR. STOCKMAN: Why don't you take some 21 time to do it. 22 Q. Yeah, by all means. 23 A. May I please. As you know I came with an 24 extensive amount of records -25 Q. Yes, sir. 0008 1 A. -- that Attorney Stockman has provided for 2 me. 3 (Pause in the proceedings.) 4 A. I assume this Exhibit 2 is the radiology 5 technician's report? 6 Q. Yes, sir. 7 A. And I do believe that I have read her 8 deposition as part of my records, but I've not seen 9 this written report previously, and it seems to 10 corroborate what I understand to be the information 11 given in her deposition, so thank you for letting me 12 read this. 13 Q. All right. Now, with regard to Plaintiffs' 14 Exhibit 1, your report that has been disclosed to all 15 counsel in this case dated December 28, 2005, does that 16 report contain all of your expert opinions in this case 17 up to this date? 18 MR. STOCKMAN: Objection. You can 19 answer. 20 A. That's a general question, Attorney. It 21 contains many of my opinions. I'm not sure if it 22 contains all of the opinions I have in this case. I 23 think it responded to the request of Mr. Stockman 24 regarding this case.

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25 Q. Did you prepare any other reports with regard 0009 1 to your expert opinions in this case at any time? 2 A. I have no other reports. 3 Q. All right. Did you prepare any drafts of 4 your report that is dated December 28, 2005, which were 5 forwarded to the attorneys for Danbury Hospital? 6 A. I have -- that were forwarded to Attorney -7 Q. The attorneys for Danbury Hospital? 8 A. The only communications I've had is with 9 Mr. Stockman. 10 Q. My question was did you ever prepare a draft 11 version of Plaintiffs' Exhibit 1 which was sent to the 12 attorneys for Danbury Hospital? 13 A. I believe not. 14 Q. Okay. Now, with regard to -15 A. This should be the only copy of my written 16 report. 17 Q. Okay. With regard to Plaintiffs' Exhibit 1, 18 this report, did you write that report entirely on your 19 own? 20 A. Yes, sir. 21 Q. Okay. Did you prepare or maintain any notes 22 aside from this report concerning your expert opinions 23 in this case? 24 A. I believe that over the course of reviewing 25 all this paper I have notes, written notes that would 0010 1 be on the back of some of the communications, nothing 2 of which is anything more than summary information of 3 review of this voluminous data. 4 Q. Okay. 5 MR. LANNI: Would it be possible for 6 Counsel to obtain photocopies of those 7 reports, of those notes and provide them to 8 all attorneys? 9 MR. STOCKMAN: Yes. 10 A. I would just suggest at this point that the 11 amount of written material I have in this case is 12 rather small. 13 Q. Okay. Understand. 14 A. I'll look through the materials, and if 15 there's any handwritten notes, I'll photocopy them for 16 you. 17 Q. Thank you. Could you tell us when were you 18 first contacted with regard to reviewing this case and

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19 providing expert opinions? 20 A. Might apologize for my lack of knowledge of 21 being sure, because I think I was contacted sometime in 22 the distance to initially discuss the case with 23 Dr. Stockman, although no records were received, 24 perhaps. 25 Q. Okay. 0011 1 A. And then as the records came, I have many 2 communications, as you can see, from Neubert, Pepe & 3 Monteith's office regarding continued communications of 4 this information. Am I being clear? 5 Q. Yes, you are. 6 A. In other words, records have been forthcoming 7 over several months, and as you can see I have many 8 communications with the office. I'm at loss to tell 9 you exactly when I was contacted by the firm initially. 10 Q. Could you give me an approximate date? 11 A. Approximate of the communications are in the 12 late months of 2005, but I may have talked to an 13 attorney on the case the year previous. 14 Q. All right. Is there any way for you to 15 approximate or estimate when you were first retained as 16 an expert witness in this case? 17 A. It is possible -- my staff will be here 18 shortly -- to review any of my bills, I may be able to 19 get a better idea of when I first was contacted by the 20 firm, and I'll be happy to get that information in the 21 next few moments. 22 Q. Okay. Because I -- you anticipated my next 23 question, which is that you did bill for the time that 24 you spent reviewing materials in connection with this 25 case; correct? 0012 1 A. I have sent bills and been paid for my time 2 review to date, yes. 3 Q. Okay. 4 A. And I'll be happy to get that information for 5 you. 6 Q. All right. Did you charge a particular rate 7 for reviewing these materials and preparing your 8 report? 9 A. My usual and customary rate for medical 10 review of legal cases is a standard $450 per hour of 11 time. 12 Q. Okay. And that is for reviewing materials?

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13 A. My rate is usually the same whether I'm 14 reviewing materials, in court, giving depositions, 15 traveling, et cetera. 16 Q. All right. And that would also include time 17 spent preparing a report? 18 A. Yes, sir. 19 Q. Okay. Can you estimate for me the total 20 amount that you have billed with regard to your expert 21 opinions in this case? 22 A. I'd be happy more than happy to tell you 23 exactly hours I billed as soon as I can get the bills. 24 We've had several hours of case review and reading, 25 rather than estimate, I'd prefer just to give you the 0013 1 exact number, if I may. But I would say many. 2 Q. And we'll ask for copies of all your bills 3 that have been submitted to date. 4 A. Off the record. 5 (Pause in the proceedings.) 6 Q. Did you have any meetings or telephone 7 conferences with the attorneys for the defendant 8 hospital with regard to your expert opinions in this 9 case? 10 MR. STOCKMAN: You're talking about me? 11 He testified he's only spoken to me. Is that 12 what you're asking? 13 Q. In general, I don't know he's only spoken to 14 you or anybody else, so -15 A. The answer to the question, the only 16 communication I've had with anyone in this case has 17 been Attorney Stockman. I've not had any conversations 18 with any of the principals in this case, no attorneys, 19 no hospital representatives. The only communications 20 I've had is either by telephone or in person with 21 Attorney Stockman. And I believe his office has 22 provided me entirely with all the materials that I've 23 had a chance to review in the case. 24 Q. Okay. Now, with regard to face-to-face 25 meetings that you had with Mr. Stockman -0014 1 A. Yes. 2 Q. -- to discuss your expert opinions in this 3 case, can you tell me how many face-to-face meetings? 4 A. We've had two face-to-face meetings. We've 5 had a handful of telephone conversations. Attorney 6 Stockman came to my office one time last week and we

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7 reviewed details of the case in general sense in this 8 room, and then we met again today, this morning before 9 this meeting for approximately one half hour. 10 Q. Okay. 11 A. Again to discuss the details and for him to 12 review many of the records that I've to date. 13 Q. No other face-to-face meetings with 14 Mr. Stockman? 15 A. None social, professional, or otherwise. 16 Q. And with regard to the first meeting you had 17 with him, how long did that take? 18 A. That was approximately a 45-minute meeting, 19 during which I again had to run off because of clinical 20 responsibilities. I think I'm identifying my time here 21 in these depositions as scattered. 22 Q. With regard to very early morning occurring 23 today, how long did that meeting take? 24 A. We met perhaps 15, 20 minutes. 25 Q. How many telephone conferences have you had 0015 1 with Mr. Stockman to discuss your -2 A. Two or three, perhaps. 3 Q. Did any of those telephone conferences take 4 place prior to the time that you authored your report? 5 A. Yes, sir, they did. 6 Q. How many? 7 A. There were perhaps two. Somewhere in my 8 vague recollection I may have talked to Attorney 9 Stockman in general terms about this case over a year 10 and a half ago and we discussed the general details. 11 He may have tried to identify whether I might be a 12 useful or helpful expert in this case. 13 We began to talk more seriously about the 14 case when he felt I was a useful expert, and at that 15 point he shared with me the records, and we discussed 16 the case in general terms and then specific. 17 Q. Okay. Now, with regard to the materials that 18 you reviewed in formulating your expert opinions -19 A. Yes, sir. 20 Q. -- are all of them identified in your report 21 dated December 28, 2005? 22 A. Unfortunately, I believe the answer to that 23 is no. 24 Q. Okay. 25 A. However, the only materials that I'm aware 0016

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1 of, which came to me more recently, were those that 2 would have been generated more recently than that date 3 of December 2005. In other words, I believe other 4 depositions were forwarded to me for my review as they 5 were generated. I believe that is an entirely accurate 6 description of all the records that I've reviewed and 7 all the depositions and written material up to the date 8 of that. 9 Q. Report? 10 A. Report. 11 Q. Okay. Can you tell me what other materials 12 you reviewed which are not identified in this report? 13 A. For example, I have a letter dated January 14 27, 2006, from Neubert, Pepe & Monteith which includes 15 an expert report submitted on behalf of Dr. Catania 16 that was generated on December 12, 2005, and that is 17 information that was not included in my original 18 report. 19 Q. And you read that expert's report? 20 A. Yes, sir. Yes, sir, I did. I also have an 21 article that was sent to me by Attorney Stockman from 22 Journal of American Medical Association which was 23 published after my report, which is also used in 24 helping formulate my opinion, and this was published 25 after my report or this was available to me after my 0017 1 report that I've written. 2 MR. LANNI: Again, I would ask for a 3 copy of that article. 4 MR. STOCKMAN: Sure. 5 Q. Okay. 6 A. I also have -- I just get the title on the 7 article. 8 Q. Sure. Why don't we just note for the record, 9 Doctor, if you could please, the title of the article 10 and the author. 11 A. The title, first document's "Rhythm and 12 Clinical Outcome from In-Hospital Cardiac Arrest Among 13 Children and Adults." It was published by Vindy M. 14 NadKarni, M.D. -15 Q. And a number of other physicians? 16 A. -- et al, published in the Journal of Medical 17 Association, and this was a study from the University 18 of Pennsylvania School of Medicine. 19 Q. Any other materials that you reviewed in 20 formulating your opinion in this case that are not

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21 identified in your report? 22 A. I think probably not. 23 Q. Okay. Dr. Teiger, have you previously 24 testified in court as an expert witness in medical 25 malpractice cases? 0018 1 A. Yes, sir, I have. 2 Q. Okay. And could you tell us and approximate, 3 if you need to, the total number of times that you have 4 testified as an expert witness in medical malpractice 5 cases? 6 MR. STOCKMAN: In court or in 7 deposition? 8 MR. LANNI: In court. 9 Q. Sir, first in court. 10 A. I would suggest half a dozen cases I have 11 actually been in court testifying as an expert witness. 12 Q. Okay. And have you testified at depositions 13 as an expert witness in medical malpractice cases? 14 A. I have testified in several depositions for 15 medical malpractice cases as an expert over the years 16 that I've been in practice. 17 Q. And could you tell us the approximate number 18 of times? 19 A. Perhaps twice the number that I've actually 20 been in court. Many cases have settled before trial, 21 as you know. But I've been deposed as an expert 22 witness many times. 23 Q. Now, do you have any type of records or 24 materials which would document the cases in which you 25 have testified, either in court or at a deposition, as 0019 1 an expert witness in medical malpractice cases? 2 MR. STOCKMAN: Objection. You can 3 answer. 4 A. I really never made a habit of keeping track 5 of the records. 6 Q. All right. Is there any way -- is there any 7 way that you can identify for us the medical 8 malpractice cases in which you have testified in court 9 as an expert witness? 10 A. Unfortunately, I'm sure that I would not be 11 able to generate that information. This is not 12 something that I keep active records on. The 13 malpractice cases have come up over years and represent 14 only a small fraction of what I do in my practice, so

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15 in general I do not keep records. I suppose in general 16 terms if I were pushed, I could come up with some of 17 the non-specifics of cases that I've been involved with 18 medical malpractice. 19 Q. Backtracking just a little bit, you told us 20 that you had testified at depositions as an expert 21 witness, is there any way that you can estimate the 22 number of depositions in which you've testified as an 23 expert witness? 24 A. I'm sorry, I just don't think I can generate 25 that data for you. I also do a large amount of legal 0020 1 work for asbestos occupational cases in the State of 2 Connecticut, and I'm involved with legal depositions 3 for those cases. And malpractice cases and product 4 liability cases sometimes get mixed. 5 I do keep records of all the legal work that 6 I do and I've done for the past five years, and if need 7 be, I can get that report and then we can go through 8 each case, which one may be the malpractice versus the 9 occupational cases. 10 I probably have over 300 cases I've been 11 involved with in the past four, five years, most of 12 which are the asbestos product liability work that I'm 13 expert for. So if it's necessary, I suppose that would 14 be one way we can dig up that information. 15 Q. Let me ask you this: Well, when you say you 16 have some type of records that indicate the legal 17 matters that you've been involved in as an expert 18 witness -19 A. Yes. 20 Q. -- in what form would those records be? 21 A. These are my personal records that I keep on 22 the legal work that I do as a portion of my practice 23 that's on Excel spreadsheet which I keep at home for my 24 personal records. 25 Q. Do they list information pertaining to each 0021 1 case? 2 A. They are actually very thorough as to the 3 name of the case, the attorney firm involved, the 4 amount that I've charged, whether I've generated a 5 formal written report, whether I've been deposed, et 6 cetera. The records would actually be the way for me 7 to identify which legal cases I've been involved with 8 for the past five years. I have been in practice for

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9 23 years now, and prior to that I've been involved over 10 the years on occasional malpractice cases, cases which 11 I may not have records for. 12 Q. Okay. 13 A. But at least in the past five years that 14 would be some way for us to identify the cases I've 15 been involved with. 16 Q. I would call for production of the records 17 pertaining the last five years that reflect the cases 18 in which you've testified as an expert witness. 19 MR. LANNI: Just note that's a discovery 20 request in this deposition. 21 Q. Now, with regard to the medical malpractice 22 cases in which you have testified either in court or at 23 a deposition as an expert witness, could you tell us in 24 some way, either the percentage or the total number, of 25 those matters in which you have testified on behalf the 0022 1 defendant? 2 A. Again, I don't keep accurate records of that. 3 However, I have never identified myself as an expert 4 for either plaintiff or defense. I've identified 5 myself as an expert in the field, and I have been 6 deposed, reviewed cases, and testified for both sides 7 over the years. In general, I have identified myself 8 as available to both sides if requested. To the best 9 of my recollection the majority of cases that I have 10 testified in have been on the side of the defense. 11 Q. All right. Is there any way you can estimate 12 the percentage of cases in which you have testified as 13 an expert on behalf of the defense? 14 A. To the best of my recollection I only 15 remember two cases that I've testified for the 16 plaintiff, therefore the rest would be for the defense. 17 The majority. 18 Q. Now -19 A. And I'm sorry for being vague, but that's the 20 best I can do to my recollection. 21 Q. You don't have to apologize. It's 22 understood. With regard to the medical malpractice 23 cases in which you have testified as an expert witness, 24 either in court or at a deposition, have they all been 25 within the State of Connecticut? 0023 1 A. No, sir, they have not. 2 Q. Okay. What other states have you testified

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3 in at medical malpractice cases? 4 A. I have testified in New York City, in 5 Brooklyn, to the best of my recollection, in one 6 medical malpractice case. 7 Q. Okay. Any other locations outside the State 8 of Connecticut? 9 A. To the best of my recollection my experience 10 has been entirely within the State of Connecticut. 11 Q. Now, you told us that you have testified as 12 an expert witness in asbestos products liability cases? 13 A. That is correct. 14 Q. Can you estimate how many of those cases you 15 have testified either in court or at a deposition as an 16 expert? 17 A. I have written reports as an independent 18 medical evaluator on literally hundreds of cases over 19 the years, since that's an interest and a subspecialty 20 of mine. Of those cases I have been deposed many times 21 by counsel for my opinion in those cases. Occasionally 22 I've been to court to discuss those cases as an expert 23 witness. 24 I have been called upon to be an expert 25 witness, as an expert in many mesothelioma cases. I 0024 1 have written reports on several of those cases. I 2 would estimate the total cases that I've been involved 3 as asbestos over the years is close to 300 cases. 4 Q. Okay. With regard to your involvement as an 5 expert witness in the asbestos cases, can you estimate 6 how many of those 300 cases were on behalf of the 7 defense and how many were on behalf of the plaintiff? 8 A. The majority of cases that I've been involved 9 with have been on the side of the defense. I've been 10 involved with my patients as an expert, which would be 11 as the plaintiff side in several. Again, the numbers 12 are not forthcoming with accuracy to me, but we're 13 talking about an estimation. 14 Q. Have you testified previously as an expert 15 witness for Mr. Stockman's firm, Neubert, Pepe & 16 Monteith? 17 A. To the best of my recollection the answer is 18 no. 19 Q. Have you testified previously as an expert 20 witness for any of the other defense firms involved in 21 this case, the firms of Ryan, Ryan, Johnson & Deluca or 22 Halloran & Sage?

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23 A. To the best of my recollection the answer is 24 no. 25 Q. All right. And same question with respect to 0025 1 Mr. Grady's firm, Rende, Ryan & Downes? Not to leave 2 him out. 3 A. To the best of my recollection the answer is 4 no. 5 Q. Now, you mentioned you reviewed other medical 6 malpractice cases on behalf of attorneys cases that did 7 not go to trial; correct? 8 A. That is correct. 9 Q. And can you estimate for me the number of 10 cases in total that you have reviewed for attorneys in 11 terms of medical malpractice actions? 12 A. I would suggest that the number probably is 13 in the range of several dozen over the years. I 14 frequently get called by attorneys to give informal 15 opinions on the cases with review of records, and more 16 often than not no report is requested. I have reviewed 17 many records on medical malpractice cases and hear 18 nothing further from the attorney after I give my 19 informal opinion. 20 In my house, which is where I do all this 21 work, I have many cases on the floor of my dining room 22 that are relatively active but have been lingering for 23 years. So the number probably is somewhere in the 24 several dozen cases of malpractice cases that I have 25 reviewed or discussed with attorneys informally, and 0026 1 then some go to be more formal, and I'm sure you know 2 the process. 3 Q. Well acquainted with it. 4 A. Yes. 5 Q. Now, with regard to the total number of cases 6 that you've reviewed for attorneys, is there any way to 7 estimate the number that you have, in which you have 8 testified for the defense, I'm sorry, in which you have 9 reviewed the materials for the defendants as opposed to 10 plaintiffs? 11 A. Probably the vast majority of opinions -- of 12 cases which I have reviewed have been generated by 13 attorneys for the defense. My opinions with regard to 14 the total number of cases that I've reviewed could end 15 up on both sides. I try to maintain my identity as an 16 independent evaluator, and sometimes I will be clear

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17 with the attorney that the case seems very clearly one 18 of malpractice or bad outcome and my opinion is what it 19 is. So of all the cases that I reviewed, while most 20 are generated by the defense, the opinions could be 21 anywhere. 22 Q. Now, have you ever reviewed any materials in 23 cases for Mr. Stockman's firm, Neubert, Pepe & 24 Monteith, other than this case? 25 A. To the best of my recollection the answer 0027 1 would be no. 2 Q. Have you ever reviewed any materials with 3 regard to this case for the other defense firms 4 involved in this case? 5 A. To the best of my recollection the answer 6 would be no. 7 Q. Have you ever been represented in a legal 8 matter by any of the defense firms involved in this 9 case? 10 A. I have never been sued for malpractice. I've 11 never had a case arise against me, and I have never 12 been represented by any of the firms involved in this 13 case. 14 Q. Okay. And I'm not limiting my question to 15 medical malpractice cases, I'm just asking you with 16 regard to representation in any legal matter. 17 A. In my past, in 2001 a consent decree was 18 issued against my practice for what we consider a 19 trivial issue that arose with regard to processing of 20 x-ray materials in my office. The consent decree was 21 generated in 2001, and since I began my practice in 22 1983, that's the only legal issue that's ever arisen 23 against me or my practice. 24 Q. What I'm interested in, with respect to that 25 legal matter were you represented by any of the firms 0028 1 involved in this case? 2 A. No, sir. 3 Q. Okay. Now, your CV, correct me if I'm wrong, 4 lists a number of hospital affiliations; correct? 5 A. That is correct. 6 Q. If you could just tell me your hospital 7 affiliations for the record? 8 A. I'll be happy to do so. May I ask the date 9 of that CV you have? 10 MR. STOCKMAN: August 20, 2005.

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11 A. Nothing much is changed since then, but, 12 obviously, we're in February of 2006. My primary 13 hospital affiliation is Saint Francis Hospital Medical 14 Center in Hartford, Connecticut. I have maintained 15 courtesy privileges at Hartford Hospital, at Manchester 16 Hospital, at the University of Connecticut Health 17 Center. 18 I have staff privileges at the Rocky Hill 19 Veteran's Home and Hospital. I'm active staff at the 20 Rehab Hospital of Connecticut, which is an affiliate of 21 Saint Francis Hospital and Medical Center, and I 22 believe that's it, all inclusive. 23 Q. Okay. What is the nature of your affiliation 24 with Saint Francis Hospital? 25 A. I am a private practitioner in private 0029 1 practice at my own office at 1000 Asylum Avenue. I am 2 a senior medical attending at Saint Francis Hospital, 3 and I have full privileges to practice medicine at the 4 hospital. 5 I have over the years become the director of 6 the hospitalists program at Saint Francis, which is a 7 fairly active and busy program in the hospital now, and 8 my work includes full hospital care of patients, 9 including pulmonary, critical care medicine, and 10 general hospital medicine. 11 Q. Okay. Now, with regard to any of the 12 hospitals that you are affiliated with -13 A. Yes. 14 Q. -- do you know if any of the law firms 15 involved in this case represent those hospitals in 16 medical malpractice matters? 17 A. I'm sure that over the years there must be 18 some affiliation between these firms and Saint Francis 19 Hospital, but to the best of my knowledge the answer 20 would be no. 21 Q. Okay. Do you know whether Saint Francis 22 Hospital -- do you know in particular whether Saint 23 Francis Hospital has ever been represented by Neubert, 24 Pepe & Monteith, Mr. Stockman's firm? 25 A. No, sir, I don't. 0030 1 Q. Now, your CV does not provide any information 2 with regard to publications that you may have authored 3 or co-authored in your career? 4 A. Yes, sir.

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5 Q. And your CV indicates that you are board 6 certified in the field of internal medicine? 7 A. That is correct. 8 Q. And also in the subspecialty of pulmonology? 9 A. That is correct. 10 Q. Okay. Have you authored or co-authored any 11 articles or publications or medical literature of any 12 kind in the field of internal medicine during your 13 career? 14 A. The publications that I've ever been involved 15 with are years old now and were generated when I was a 16 fellow in pulmonary medicine. I consider them trivial 17 and insignificant to my career and I've chosen not to 18 list those publications. In fact, they're so old now 19 that I'm not sure what value they were. 20 Just as a comment, I have made my career 21 entirely one of clinical practice of medicine and 22 hospital work, and I do not consider myself a 23 researcher by any stretch. As you can see from my CV, 24 I have been involved with several research programs 25 that have been generated along the way through Saint 0031 1 Francis as an investigator, but many of these did not 2 end up in the generation of literature. So while I 3 have been involved in the field of research in many 4 different aspects, I do not have a publication list 5 available. 6 Q. Have you with respect to any of the medical 7 literature that you may have authored or co-authored, 8 did any of that involve critical care issues? 9 MR. STOCKMAN: Objection. You can 10 answer. 11 A. I'm sure somewhere along the way the answer 12 to that question would be yes. For example, case 13 reports of critical care patients that I've been 14 involved with as a senior medical attending may have 15 been written as case reports for literature by junior 16 pulmonary fellows or young practicing physicians, and I 17 may be included in the author list as a senior medical 18 attending, but not having been the primary author of 19 the report. 20 Q. Well, do you maintain any records or other 21 materials which would indicate the medical literature 22 in which you are identified as a co-author? 23 A. I felt that that information is not important 24 to my career and I have not maintained that

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25 information. I have a feeling if the index medicus was 0032 1 researched, my name would come up at some point over 2 the past many years as being included as an author. I 3 have not included that as part of my CV. 4 Q. Would you have maintained copies of the 5 medical literature itself that you have that -- on 6 which you were listed as a co-author in your office or 7 at your home? 8 A. The answer is absolutely not, no, sir. 9 Q. Now, with regard to your report dated 10 December 28, 2005, you rendered certain opinions with 11 regard to the care rendered by the surgeons and the 12 hospital staff in this case. 13 MR. STOCKMAN: Objection. You can 14 answer. 15 Q. Is that correct? 16 A. Yes, sir. 17 Q. Okay. Would it also be correct for me to say 18 that your report sets forth certain opinions regarding 19 the cause of the brain damage sustained by this 20 patient? 21 MR. STOCKMAN: Objection. You can 22 answer. 23 A. The answer is yes. 24 Q. Okay. Now, in your report you set forth 25 certain opinions regarding the care rendered by the 0033 1 nursing staff at Danbury Hospital, isn't that true? 2 (Pause in the proceedings.) 3 A. I do give an opinion with regard to the 4 nursing staff. 5 Q. Yes. Okay. 6 A. Yes. 7 Q. And with regard to those opinions, do you 8 consider yourself qualified to render opinions about 9 nursing care? 10 A. Yes, sir, I do. 11 Q. Okay. And why do you consider yourself 12 qualified to render opinions about nursing care? 13 A. My entire hospital professional work involves 14 the interaction with the care of patients between the 15 physician work and the nurses. Over the years I have 16 huge interaction with the responsibilities of nurses 17 and understand what their responsibilities and 18 requirements are in order to give what we consider to

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19 be the best patient care available. So my knowledge of 20 nursing care comes from my fairly extensive interaction 21 of hospital work at my hospital, Saint Francis, over 22 the years, as well as other institutions. 23 Q. All right. So what you are saying, and 24 correct me if I'm wrong, is that your experience in 25 working with the nursing staff at Saint Francis and 0034 1 other hospitals leads you to believe that you're 2 qualified to render opinions about nursing care? 3 A. I think it would be a normal expectation that 4 physicians who work closely with nurses and in the 5 hospital on a day-to-day basis to the extent that I do 6 would know the responsibilities and requirements of 7 nursing in general and in specific. Of course, I don't 8 have a nursing degree, but I don't believe that is 9 required to make me aware of what nursing 10 responsibility is. 11 Q. All right. So let me just clarify what 12 you're telling me. You're saying that you consider 13 yourself qualified to render opinions about the quality 14 of nursing care based upon your experiences and 15 interactions with the nursing staff at Saint Francis 16 Hospital and the other hospitals that you've been 17 affiliated with in your career; is that what you're 18 saying? 19 MR. STOCKMAN: Objection. And he can 20 answer, but he's already answered this 21 question in two forms. You can respond. 22 A. I think that would be a fair statement. 23 Q. Now, if you could just turn to your report, 24 sir. And I'm going to draw your attention to page two 25 of your report, and the second full paragraph in that 0035 1 report. 2 A. Yes. 3 Q. And the first sentence in that report reads, 4 "Mr. Guigliano suffered a cardiopulmonary arrest on 5 February 17, 2001, due to compromised lung function as 6 a result of progressive abdominal distention." Now, 7 what I've just read to you, that's one of your opinions 8 in this case; correct? 9 A. That's a general statement, yes, regarding 10 his case. 11 Q. Okay. That would be one of your opinions? 12 A. I would have to say yes, since I've written

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13 it in the report. 14 Q. In your opinion how did progressive abdominal 15 distention cause compromised lung function in this 16 patient? 17 A. Abdominal -- progressive abdominal distention 18 would impair any patient's ability to take deep, full 19 breaths and use his lungs to full capacity. 20 Q. Okay. And with regard to the opinion -21 withdrawn. 22 With regard to this particular aspect of your 23 opinion, could you tell us what is the basis of that 24 opinion in the materials that you reviewed? 25 A. Hopefully you won't ask me to go to specific 0036 1 pages, but I think it was a well-documented issue that 2 the patient's abdomen was distended, and this was a 3 problem he had on the floor for several days, so 4 abdominal distention is identified in the medical 5 records as existing. 6 Q. Okay. 7 A. And from a pulmonologist point of view we 8 know that abdominal distention can impair pulmonary 9 function on a normal pathophysiological basis, which 10 I'll be happy to describe, if you like. 11 Q. Yes, sir, please. 12 A. Respiration requires the ability of the lungs 13 to expand. The total ability of a patient's lung to 14 expand is documented as total lung capacity, which for 15 any given individual is identified as a number. If a 16 patient has abdominal distention, the total lung 17 capacity would be reduced because the abdominal 18 distention would impair a patient's ability to take a 19 full, deep breath. 20 So abdominal distention would impair total 21 lung capacity in a similar fashion to pregnancy with 22 abdominal distention would impair total lung capacity. 23 This is something that is recognized as normal 24 physiology or pathophysiology in this case, and this 25 patient's abdominal distention would have compromised 0037 1 his respiratory capabilities. 2 Q. Okay. Now, in your opinion how did the 3 compromised lung function secondary to this progressive 4 abdominal distention cause or contribute to the 5 cardiopulmonary arrest of this patient on February 17, 6 2001?

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7 MS. HUNT: Object to the form. 8 MR. STOCKMAN: Objection. You can 9 answer. 10 A. Loss of total lung capacity, loss of 11 ventilatory ability, loss of this patient's ability to 12 use his lungs to full capacity, would in a general 13 sense contribute to overall physiological 14 deterioration. It is not my implication that abdominal 15 distention was the entire cause of Mr. Guigliano's 16 cardiopulmonary arrest, but it certainly contributed by 17 preventing him from having full respiratory ability. 18 We do know that his oxygen saturation was 19 measured as compromised just prior to the arrest, and 20 the oxygen saturations of 70 to 80 percent, where it 21 should be well above 90 percent. So we do know that 22 his respiration function was compromised. The 23 abdominal distention to me was clearly an indication, 24 was manifested by a low oxygen saturation. I hope 25 those comments are helpful. 0038 1 MR. LANNI: If you could just read back 2 that last portion of his response, the last 3 two sentences, if you could. 4 (Answer read.) 5 (Answer reread.) 6 Q. So are you saying that the low oxygen 7 saturation was either in whole or in part caused by the 8 abdominal distention? 9 MS. HUNT: Object to the form. 10 MR. T. GRADY: Objection to the form. 11 MR. STOCKMAN: Objection. You can 12 answer. 13 A. The way you phrased the question is a little 14 bit difficult, but in a ill patient who has many 15 medical problems and processes going on, everything 16 contributes to his overall deterioration. From a 17 pulmonologist's point of view, the low oxygen 18 saturation contributes to his overall difficulty, as 19 does the abdominal distention. 20 My suggestion to you is that the abdominal 21 distention contributed to his low oxygen saturation 22 because he was unable to ventilate to full capacity. 23 Of course, we know that the significant portion of his 24 illness was his pseudomembranous colitis, which was in 25 large part the cause of his abdominal distention, 0039

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1 associated with his pain medication that he was getting 2 and lack of proper bowel function. 3 So I believe this man was ill and his 4 difficulty was multifactorial, but certainly his 5 respiratory compromise on the basis of his abdominal 6 distention was a large factor. 7 Q. Okay. Now, you described this patient as 8 being ill and that his difficulties were 9 multifactorial, could you tell us what do you mean by 10 that? 11 A. The patient was ill because he was in the 12 hospital under care, and his illness had to do with 13 many things, including his recovery from the fractured 14 ankle, the abdominal distention which he had for 15 several days, his anxiety and distress about being in 16 the hospital and being laid up and immobile. There 17 were many factors involved in his overall difficulty. 18 By "ill," I mean that the patient clearly required to 19 be in the hospital because he had medical difficulties. 20 Q. When you described this patient as ill and 21 having difficulties that were multifactorial in nature, 22 would that necessarily include his respiratory 23 compromise? 24 A. I think his respiratory status was considered 25 stable and adequate for floor monitoring and floor 0040 1 evaluation. 2 Q. I'm just asking you is that one of the 3 factors that leads you to conclude that this patient 4 was ill? 5 A. Yes, sir. 6 Q. Okay. Now, I believe you testified, and 7 correct me if I'm wrong, that the abdominal distention 8 was not the entire cause of the cardiopulmonary arrest; 9 correct? 10 A. That is my opinion, yes. 11 Q. Okay. And could you tell me in your opinion 12 what other causes were there of the cardiopulmonary 13 arrest? 14 A. We do know that this patient had a 15 significant pseudomembranous colitis, was -- and 16 identified to have an ileus on a clinical basis by his 17 physicians, he was in significant pain and required 18 narcotic analgesics. At the time of the decision to 19 get a CAT scan the surgeons felt that it was 20 appropriate to evaluate his abdomen because of the

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21 distention, because of the persisting difficulty with 22 bowel dysmotility and his overall poor condition. 23 Q. Okay. Well, when you describe him as being 24 in overall poor condition, what factors lead you to 25 describe him as being in "overall poor condition"? 0041 1 MR. STOCKMAN: Objection. You can 2 answer. 3 A. I wonder if you could be a little more 4 specific how you would like me to answer you with 5 regard to his clinical state. 6 Q. Well, you're the one who used the term 7 "overall poor condition," I'm just asking you what do 8 you mean by that? 9 A. That would be a better way to answer the 10 question, I think. I think Mr. Guigliano was ill, I 11 think his abdomen was not functioning properly, his 12 bowels were not functioning properly. I think he 13 needed to be in the hospital under care and 14 observation. I think he was ill. By those statements 15 I want to imply I think he did not require intensive 16 care unit level of treatment. If there are any other 17 comments about what degree of illness, I hope you can 18 help direct me with your questioning. 19 Q. Okay. Well, when you classified this patient 20 as being in "overall poor condition," you're referring 21 in part to his abdominal distention; correct? 22 A. Correct. 23 Q. And you're referring in part to his 24 pseudomembranous colitis; correct? 25 A. Correct. 0042 1 Q. And you're referring in part to his 2 compromised lung function; correct? 3 A. Correct. 4 Q. Okay. 5 A. And those are the issues that lead me to tell 6 you that the patient is ill. 7 Q. Okay. And you're referring in part to his 8 problems with oxygen saturation? 9 A. Again, it's a factor, yes. 10 Q. Okay. Now, you told us in your report that 11 the patient's cardiopulmonary arrest was due to 12 compromised lung function as a result of progressive 13 abdominal distention? 14 MS. HUNT: Objection to form.

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15 MR. T. GRADY: Objection to form. 16 MR. STOCKMAN: Objection. 17 Q. Correct? 18 A. I didn't mean to imply in any way that was 19 the only factor responsible. 20 Q. And therein Mr. Guigliano suffered 21 "cardiopulmonary arrest on February 17, 2001, due to 22 compromised lung function as a result of progressive 23 distention -- abdominal distention." Do you identify 24 any other causes of the respiratory arrest? 25 MS. HUNT: Objection. 0043 1 Q. Cardiopulmonary -2 MS. HUNT: Objection. Object to the 3 characterization of the question, and it 4 takes out of context the entirety of the 5 paragraph. 6 MR. STOCKMAN: I'll join the objection 7 as well. If you understand the question, you 8 can answer it. 9 A. I think I understand it. I would like to 10 state for the record that I think the cause of the 11 cardiopulmonary arrest is multifactorial. I do not 12 mean to imply in any way that the low oxygen saturation 13 was the sole issue involved in this case. 14 Q. I'm just asking you with regard to this 15 particular sentence that leads off this paragraph, does 16 it identify any other cause of the cardiopulmonary 17 arrest? 18 A. I think the sentence needs to be identified 19 for what it is. But stating for the record here today, 20 I'd like to clarify the best I can that I do not 21 believe that the low oxygen saturation only is the 22 entire cause of his cardiopulmonary arrest, and if my 23 sentence implies that, then I hope to modify that by my 24 deposition today. 25 Q. We'll get to that. But my question is with 0044 1 regard to this particular sentence. 2 MR. STOCKMAN: You're just asking has he 3 laid out the other alternative in this; is 4 that correct? 5 Q. Let me ask the question again. All right. 6 With regard to this sentence, "Mr. Guigliano suffered a 7 cardiopulmonary arrest on February 17, 2001, due to 8 compromised lung function as a result of progressive

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9 abdominal distention," do you identify any other causes 10 of the cardiopulmonary arrest, yes or no? 11 A. Again, I think the cause of the 12 cardiopulmonary arrest is multifactorial, and in that 13 regard I think that there are other factors that are 14 the cause of the cardiopulmonary arrest. 15 Q. That's -- those are not identified in this 16 particular sentence I read to you? 17 A. Of course not. 18 Q. Okay. Now, aside from progressive abdominal 19 distention causing compromised lung function, could you 20 list for me the other factors that in your opinion 21 caused or contributed to the cardiopulmonary arrest of 22 this patient on February 17, 2001? 23 A. I can identify the toxicity from 24 pseudomembranous colitis as a cause, as a potential 25 cause. I can identify ileus as a potential cause. I 0045 1 can identify the injury due to his fall as a potential 2 cause. I can identify his general anxiety and debility 3 in the hospital as a potential cause. I can also 4 speculate as to any one of other issues which may have 5 contributed which I cannot define due to the data I 6 have available. 7 Q. All right. Now -8 A. But I prefer not to speculate, unless you 9 would like me to do so. 10 Q. Oh, no, I'm not interested in your 11 speculation, I'm interested in your opinions. 12 A. Sometimes opinions are speculation, sir. 13 Q. Well, I'm interested in your opinions that 14 are based on degree of medical certainty or medical 15 probability. Okay? 16 A. I understand. 17 Q. Okay. Now, you mentioned that "toxicity from 18 pseudomembranous colitis" was a potential cause or a 19 contributing factor in the patient's cardiopulmonary 20 arrest; correct? 21 A. I think that would be a correct statement, 22 yes. 23 Q. Okay. And when you wrote your report on 24 December 28, 2005, you were aware of the fact that this 25 patient had been diagnosed with pseudomembranous 0046 1 colitis; correct? 2 A. From review of the record pseudomembranous

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3 colitis was proven by culture. 4 Q. Okay. And can you tell me where in your 5 report you specifically state that toxicity from 6 pseudomembranous colitis is a potential cause or 7 contributing factor to this patient's cardiopulmonary 8 arrest? 9 A. By the way you've asked the question, I don't 10 believe that I state that specifically. 11 Q. Okay. Now, you mentioned that ileus was a 12 potential cause or contributing factor in this 13 patient's cardiopulmonary arrest; correct? 14 A. In my report or in my discussions here today? 15 Q. No. In your discussions here today, I'm 16 talking about what you just testified to. 17 A. I think that's correct. 18 Q. Okay. Yes. All right. Now, you've 19 testified that ileus is a potential cause or 20 contributing factor to the cardiopulmonary arrest, and 21 my question to you is when you wrote your report on 22 December 28, 2005, you were aware that this patient had 23 been diagnosed with a ileus during his admission? 24 A. That's correct. 25 Q. Okay. And I'm asking you where in your 0047 1 report does it specifically state that ileus was a 2 potential cause or contributing factor to this 3 patient's cardiopulmonary arrest? 4 A. It does not state that. 5 Q. Okay. Now -6 A. I believe it's implied by the words that I've 7 written. But do I specifically state that ileus is the 8 cause or contributing factor, the answer is no. 9 Q. All right. 10 A. I think the second complete paragraph on page 11 two implies that ileus is a contributing factor. 12 Q. Okay. Well, how would ileus be a 13 contributing factor to the cardiopulmonary arrest? 14 A. Again, ileus would be responsible for, in 15 whole or in part, with abdominal distention. Abdominal 16 distention would cause pulmonary respiratory 17 compromise, it would cause low oxygen saturation that 18 would contribute, and I think my wording implies that 19 is an issue, although I have not stated specifically -20 Q. All right. 21 A. -- in my report that ileus contributed to his 22 cardiac arrest.

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23 Q. All right. Now, let me backtrack for a 24 moment. You testified that toxicity as a result of 25 pseudomembranous colitis would be a potential factor in 0048 1 contributing to the cardiopulmonary arrest; correct? 2 A. I think that is a correct statement, yes. 3 Q. And could you tell us how that toxicity from 4 pseudomembranous colitis would be a potential 5 contributing factor? 6 A. Any infectious disease, whether it becomes, 7 manifests systematically with general illness, 8 abdominal distention, contributes to the overall body 9 compromise, and that regard he would not be able to 10 handle insults as well as they come along. His body is 11 weakened, his defense system is weakened, he is unable 12 to handle the stresses or strains of hemodynamic 13 cardiopulmonary instability. So toxicity makes him 14 weaker and more susceptible to difficulties than an 15 otherwise healthy person. And again, I identified this 16 gentleman as being sick, requiring hospitalization. 17 Q. What is the physiological mechanism by which 18 toxicity from pseudomembranous colitis would impair 19 this patient's ability to handle any cardiopulmonary 20 instability? 21 A. We consider patients who are ill with this 22 type of toxicity as having cells which are sick. Sick 23 cell syndrome is one phrase that's in the medical 24 literature. Cells don't handle things as well, his 25 heart is not as strong, his lungs are not as capable of 0049 1 exchanging oxygen, his intestinal tract is not capable 2 of handling digestive juices, his brain is not capable 3 of handling neurological function. His cells are sick 4 in general because of the toxicity. 5 And from a layman's point of view, anybody 6 knows when they are sick with the flu they don't work 7 as well, they're unable to get up and do everything 8 that they are capable of when they're well. So I 9 consider this patient to have been toxic from the 10 pseudomembranous colitis and suffered from general body 11 cell sickness. 12 Q. Okay. Would you be able to tell us what 13 clinical evidence documented that this patient was 14 toxic from the pseudomembranous colitis? 15 A. We can go over the vital signs that might be 16 on the floor. He had abdominal distention, he was

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17 irritable, he was in pain, he had difficulty with 18 staying stable in the hospital. He was certainly not 19 calm, by any nurses notes. He manifested signs that we 20 clinically identify as patients being sick. 21 Q. When you say that this patient had difficulty 22 in staying stable in the hospital, what are you 23 referring to? 24 A. I'm talking more to movement, in the fact 25 that he seemed to be up and down from bed, the nurses 0050 1 were not able to make him comfortable at times. He was 2 irritable. 3 Q. So you're saying that the difficulty in 4 staying stable was related to his ability to move and 5 his irritability? 6 MR. STOCKMAN: Objection. You can 7 answer. 8 A. By all the nurses notes and clinical records 9 that I can see, the patient was clearly uncomfortable 10 with his ankle, with his abdomen, with his respiratory 11 status, with the frustration being in the hospital. He 12 was not a patient who was identified as comfortable and 13 happy to be where he was convalescing. 14 Q. Okay. So you're saying that when you use 15 that term "stable," you're referring to the comfort of 16 the patient? 17 A. I'm saying that's one manifestation, yes. 18 Q. Okay. 19 A. Certainly, the patient was uncomfortable. 20 Q. Let me just backtrack a little bit to the 21 toxicity issue. You told us that there was clinical 22 evidence in the Danbury Hospital chart which indicated 23 that this patient was toxic from the pseudomembranous 24 colitis; is that correct? Is that a correct statement 25 of your testimony? 0051 1 A. It's my opinion that the patient manifested 2 toxicity based on the records that I reviewed in the 3 clinical picture, yes. 4 Q. Okay. And -5 A. I'm not sure I can identify progress or 6 nursing notes today with -- all these records state 7 this patient as toxic. My opinion is that given the 8 range of difficulty that he had and the diagnosis and 9 the clinical picture, my opinion is that this patient 10 was ill and manifested signs of toxicity associated

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11 with the pseudomembranous colitis. 12 Q. Okay. 13 A. One of those manifestations would be the 14 abdominal distention and the respiratory difficulty. 15 Q. Okay. So what you're saying is that the 16 toxicity from the pseudomembranous colitis in part 17 caused the abdominal distention? 18 MS. HUNT: Object to the form. 19 MR. T. GRADY: Join. 20 MR. STOCKMAN: You can answer. 21 A. I think that's clear, my opinion, as one of 22 the contributing factors to the abdominal distention, 23 yes. 24 Q. And you're also saying that the ileus was one 25 of the contributing factors in the abdominal 0052 1 distention; correct? 2 A. That is correct. And the ileus could be 3 caused by the pseudomembranous colitis, by the narcotic 4 use, or both. 5 Q. Okay. And with regard to both the factors of 6 ileus and toxicity, would you agree with me that those 7 factors indirectly caused the compromised lung function 8 in this patient? 9 MS. HUNT: Objection to the form. 10 MR. STOCKMAN: Join. 11 MR. T. GRADY: Join. 12 A. I might object to the word "indirectly," 13 since I'm not sure how to answer that question. 14 Whether direct or indirect factor, it certainly was a 15 contributing factor. 16 Q. Of the abdominal distention? 17 A. That is my opinion, yes. 18 Q. Okay. And that abdominal distention in turn 19 caused the compromised lung function? 20 MR. STOCKMAN: Objection. You can 21 answer. 22 MS. HUNT: Objection. 23 A. I think that would be a fair statement, yes. 24 Q. Okay. Now, would -- withdrawn. 25 With regard to the issue of this patient 0053 1 being toxic as a result of the pseudomembranous 2 colitis, is that something that you would expect the 3 surgeons who were treating this patient to be aware of 4 when this patient was under their care?

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5 MR. STOCKMAN: Objection. 6 MR. T. GRADY: Object to the form. 7 MR. STOCKMAN: This witness has not been 8 disclosed as to surgical standard of care. 9 MR. LANNI: I understand. I'm not 10 asking about standard of care. 11 MS. HUNT: I think you are. 12 MR. STOCKMAN: I think you are too. I 13 think you're asking what he would expect the 14 surgeons to expect. If that's not the 15 characterization, I'm -16 Q. I'm asking would you have expected the 17 surgeons to be aware of the clinical evidence that 18 indicated this patient was toxic from pseudomembranous 19 colitis? 20 MS. HUNT: Object to the form. 21 MR. STOCKMAN: Again, objection, Doctor, 22 if you have an opinion, you can render it. 23 A. It's my opinion that the surgeons were aware 24 of the patient's toxicity and his illness because they 25 decided to pursue the difficulty the patient had with a 0054 1 CAT scan. So my opinion is the surgeons -- my opinion 2 is that I would expect the surgeons to be aware of the 3 toxicity since they were caregivers at the bedside. 4 And it is my opinion that they were aware of the 5 toxicity and decided to pursue a diagnostic evaluation 6 with the CAT scan on the day of his cardiopulmonary 7 arrest. I don't believe I'm giving a surgical opinion. 8 I believe I'm giving an opinion on the care of a 9 critically ill, modify, care of a ill patient in the 10 hospital based on their clinical evaluation and rounds 11 at the bedside. 12 Q. All right. 13 A. So I don't believe that's a surgical opinion, 14 that's a medical care opinion. 15 Q. And you would agree with me that based upon 16 the materials in the records that you reviewed, the 17 surgeons had made the diagnosis of ileus; correct? 18 A. The surgeons were aware that the abdomen was 19 distended and not functioning properly, and there was a 20 dysmotility that would be identified as an ileus, they 21 decided to pursue the cause of the ileus further with 22 the abdominal CAT scan, and that would be the 23 appropriate standard of care, the appropriate next 24 step.

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25 Q. Okay. Well, would you as a physician, would 0055 1 you have expected the physicians taking care of this 2 patient to be aware of the fact that the abdominal 3 distention in this patient was compromising his lung 4 function? 5 MS. HUNT: Object to the form. 6 MR. STOCKMAN: Objection. Again, I 7 don't want the witness to speculate. This 8 witness has not disclosed to testify the 9 standard of reasonable care applicable to 10 other physicians. 11 Q. You can answer. 12 A. It's my opinion that they were aware of his 13 abdominal distention and respiratory compromise, but 14 it's my opinion it's a question of degree. 15 Q. Okay. Well, my question is a little bit more 16 basic than that. My question is would you have 17 expected that the physicians taking care of this 18 patient would be aware that the abdominal distention 19 was compromising lung function? 20 MS. HUNT: Object to the form. 21 MR. T. GRADY: Object to the form. 22 MR. STOCKMAN: Object to the form. You 23 can answer. 24 A. It seems to me you're asking a question in 25 general terms rather than a specific of this case. 0056 1 From that point of view I think a physician caring for 2 a patient with this type of medical illness would be 3 aware that all factors involved would contribute to his 4 respiratory status. 5 In other words, the abdominal distention 6 would be an expected cause of some respiratory 7 difficulty, not necessarily critical respiratory 8 difficulty but some respiratory difficulty, that would 9 be the expected level of care a medical student would 10 possess. 11 Q. Okay. 12 MR. STOCKMAN: Could we talk? Just take 13 a five-minute break. 14 (Recess taken: 10:10 - 10:27.) 15 Q. Returning to the issue of the causes of the 16 cardiopulmonary arrest that you testified to today, I 17 believe you mentioned that his injuries due to the fall 18 were a potential cause of the cardiopulmonary arrest;

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19 correct? 20 A. I'd like to state that they were a 21 contributing cause to his cardiopulmonary arrest. 22 Q. Right, a potential -23 MR. STOCKMAN: Objection to the form. 24 It's a mischaracterization. He just said 25 he'd like to state it was a contributing 0057 1 factor. 2 Q. With respect to that, how were his injuries 3 as a result of the fall a potential contributing 4 factor? 5 MS. HUNT: Object to the form. 6 MR. STOCKMAN: Objection. You can 7 answer. 8 A. I think his injuries were significant to his 9 system by the fact that he had a fracture that was a 10 complicated fracture that caused pain, that caused leg 11 swelling, that caused him to require these narcotic 12 medication, that required him to use antibiotics, 13 therapy, which then led to his other factors, had 14 contributed to his overall general debility. So the 15 fact that his bony fracture existed began the cascade 16 of other difficulties. 17 Q. Okay. And that would include the ileus? 18 A. I think the ileus was a step, several steps 19 down the road -20 Q. Okay. 21 A. -- from his original injury. Forget he 22 required operation, he required general anesthesia, all 23 of these things are contributing factors. 24 Q. So you would you agree with me that when you 25 say his injuries from the fall are a potential 0058 1 contributing factor, would you agree that that would be 2 an indirect cause? 3 MS. HUNT: Object to the form. 4 MR. STOCKMAN: Object to the form. You 5 can answer. 6 A. I think from a medical point of view I would 7 like to characterize that as a contributing factor in 8 his overall general destabilization of good health. 9 Q. Okay. Okay. When you use that term, 10 "destabilization of good health," would you use that 11 term to describe his condition on the morning of 12 February 17, 2001?

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13 A. Was that the day he suffered the 14 cardiopulmonary arrest? 15 Q. Yes. 16 A. By that time he had a number of factors which 17 were causing him, his